If you were given full control of education in this field...

[maruchan]

What would you do?

For me:
- Drastically increase case requirements for SBRT, SRS, and brachytherapy. The current requirements for SBRT and SRS are laughable and do not reflect the current state of the field. The current requirements for brachytherapy are not enough for competent practice.
- Ban fellowships other than those that provide or deepen a skill outside of basic competencies for a radiation oncologist. Ie no palliative radiation fellowship.
- Cap the percentage of resident rotation time that can be spent at satellites rather than the main facility.
- Impose a moratorium on any further residency expansion.
- Ban 100% resident coverage for attendings. It has a definite negative impact on long-term competency.
- Reduce the pervasive cultural focus on memorizing esoterica from trials, which far outweighs other fields. Personally, I would prefer this focus to be shifted toward nuances of the treatment planning process which likely have greater impact on patient outcomes.
- Eliminate the radbio and physics exams. These are pointless and do not exist in any other specialty, and contribute minimally to clinical competency. For the relevant points, include in clinical exam.
- Establish a board that would administer every 10 years a minimal competency examination. This is not meant to be a difficult exam, but would be aimed at ensuring practicing attendings have up-to-date core competencies (for example can draw reasonable head and neck IMRT volumes).

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[medgator]

Impose a moratorium AND make every program that expanded/started in the last decade permanently shrink by 1-2 spots in next year's match

 

[thecarbonionangle]

Agree with all you said. One issue I think our field has is the widespread lack of good didactic education in many programs, where residents are primarily scribes and education is not a focus at all. This is an issue Wallner is right about. I'm not sure how to fix this. I suppose a minimal amount of didactic hours per week could be specified which would be mandatory.

 

[Phantom1]

What is the purpose of these rediculus wish lists.. ban 100% resident coverage? Some faculty have staff clinic coverage written in their contracts. What next you want to ban contracts?

 

[KHE88]

Attendings that refuse to go uncovered are a huge red flag for a number of reasons.
Med students still stubborn enough to go into this field: ask every program you interview at if there attendings ever go uncovered of if the department philosophy is to always have an attending with a resident. Cross coverage is even worse, but I think most programs have done away with that by now and made it up for it just by increasing the complement.

 

[emt409]

Where are these centers everyone keeps talking about that have such terrible didactics? Every program I ever hear about has at least 2-3h/wk of didactics plus required attendance at multiple tumor boards.

 

[medgator]

Where are these centers everyone keeps talking about that have such terrible didactics? Every program I ever hear about has at least 2-3h/wk of didactics plus required attendance at multiple tumor boards.

Smaller university and community programs typically

 

[seper]

In my personal experience, writing resident coverage into a contract is extremely uncommon. I've never seen it. In fact, university-employed physician work agreements are not contracts in strict sense, more like handshake-agreed set of rules.

What is the purpose of these rediculus wish lists.. ban 100% resident coverage? Some faculty have staff clinic coverage written in their contracts. What next you want to ban contracts?

 

[thecarbonionangle]

It is not just didactic time but quality. Many places have resident led didactics with no faculty involvement, faculty have minimal to none invovement in resident education and it is “blind leading blind”. I saw this on my rotations at multiple places as a student. I also want to clear something up so we dont fall into Wallner’s trap. It is NOT just “small programs”, as defined by him.

 

[evilbooyaa]

Attendings that refuse to go uncovered are a huge red flag for a number of reasons.
Med students still stubborn enough to go into this field: ask every program you interview at if there attendings ever go uncovered of if the department philosophy is to always have an attending with a resident. Cross coverage is even worse, but I think most programs have done away with that by now and made it up for it just by increasing the complement.

Completely agree. An attending who cannot run their service efficiently without a resident is either an incompetent one, or is at high-risk to become an incompetent one with time.

I specifically think any program that makes you cover two attendings' services at one time should be an immediate red-flag unless the attendings are mostly research scientists or like the chair.

It is not just didactic time but quality. Many places have resident led didactics with no faculty involvement, faculty have minimal to none invovement in resident education and it is “blind leading blind”. I saw this on my rotations at multiple places as a student. I also want to clear something up so we dont fall into Wallner’s trap. It is NOT just “small programs”, as defined by him.

Also agreed. Exclusively resident-led didactics without faculty involvement, especially for clinical radiation oncology, is an absolute sham and should be a strong sticking point. The PD should be at most resident-led lectures, at bare minimum. This also goes into the issue of having residents rotate at 3 or more sites, especially if there isn't a robust way to video conference in for relevant lectures.

 

[medgator]

Completely agree. An attending who cannot run their service efficiently without a resident is either an incompetent one, or is at high-risk to become an incompetent one with time.

Yup...amazing that some of us in PP carry 25-35 pts under treatment, do our own notes etc and an academic attending treating 15 needs FT resident coverage

 

[RadOncDoc21]

Yup...amazing that some of us in PP carry 25-35 pts under treatment, do our own notes etc and an academic attending treating 15 needs FT resident coverage

Also add, multiple sites vs. only doing one or two disease sites.

We don't have a residency program but I'm not going to lie, I do like it when I have an internal medicine resident rotating with me round on an inpatient. Maybe I would be that attending.. !

 

[fiji128]

It is not just didactic time but quality. Many places have resident led didactics with no faculty involvement, faculty have minimal to none invovement in resident education and it is “blind leading blind”. I saw this on my rotations at multiple places as a student. I also want to clear something up so we dont fall into Wallner’s trap. It is NOT just “small programs”, as defined by him.

This describes my program and, of course, all attendings always had 100% coverage from the residents. Some of the attendings were so bad/incompetent that they would take time off if they knew their resident was going to be out so they wouldn't have to deal with their service. Crazy part was that the Chair and PD found all of this 100% acceptable.

 

[RadOncDoc21]

This describes my program and, of course, all attendings always had 100% coverage from the residents. Some of the attendings were so bad/incompetent that they would take time off if they knew their resident was going to be out so they wouldn't have to deal with their service. Crazy part was that the Chair and PD found all of this 100% acceptable.

I feel like we may have trained at the same institution.

 

[thecarbonionangle]

This describes my program and, of course, all attendings always had 100% coverage from the residents. Some of the attendings were so bad/incompetent that they would take time off if they knew their resident was going to be out so they wouldn't have to deal with their service. Crazy part was that the Chair and PD found all of this 100% acceptable.

Please provide advice for residents in such programs. How did you navigate it? There are people reading who may find this useful.
There are attendings in some places who have no idea how to even do IMRT and need full coverage because everyone knows they are unsafe and must be watched at all times. Some of them are even “big names”. I find these situations sad. What can residents even do without harming their program and getting it shut down? I dont understand how in some places it can be acceptable to have effectively zero education.

 

[GreyingRadOnc]

There is a feedback mechanism built in to the system for bad programs that don't teach or respond to resident concerns. The resident survey is incredibly powerful both at the level of the local GME and at the level of the ACGME. It does require residents to report what is happening, but there is nothing that the ACMGE takes more seriously than the resident survey and it's the quickest way for a program to end up on probation (which can lead to termination). If your program is horrific then you owe it to yourself and future residents to be honest and descriptive on that survey. It will impact the program.

 

[thecarbonionangle]

There is a feed mechanism built in to the system for bad programs that don't teach or respond to resident concerns. The resident survey is incredibly powerful both at the level of the local GME and at the level of the ACGME. It does require residents to report what is happening, but there is nothing that the ACMGE takes more seriously than the resident survey and it's the quickest way for a program to end up on probation (which can lead to termination). If your program is horrific then you owe it to yourself and future residents to be honest and descriptive on that survey. It will impact the program.

ok so a resident ( or residents) in said program fill out survey and are honest, and either get their program shut down or get it on probation, then look for a job coming from a program on probation and nobody gives them a job, because who would want to employ people from such a horrible program on probation. There is no mechanism to take care of these residents who are doing something for the good of their program or the specialty. what place will employ them? which program will take them if they get their program shut down? if you really want people to be honest in the survey you need to give them an out. I don't think people in these programs answer honestly for these reasons.

 

[GreyingRadOnc]

ok so a resident ( or residents) in said program fill out survey and are honest, and either get their program shut down or get it on probation, then look for a job coming from a program on probation and nobody gives them a job, because who would want to employ people from such a horrible program on probation. There is no mechanism to take care of these residents who are doing something for the good of their program or the specialty. what place will employ them? which program will take them if they get their program shut down? if you really want people to be honest in the survey you need to give them an out. I don't think people in these programs answer honestly for these reasons.

Yes, but if the program is toxic, and not preparing the residents to pass their boards then the rest isn't very relevant. I don't think RadOnc has faced anything similar to this TBH (program closing). I had a friend in Urology and the program he matched to closed. Urology absorbed all those trainees and my friend ended up graduating from a top tier program. What would Rad Onc do? Not sure, but no one is benefited from maintaining a toxic program. Also, the year you complain, the ACGME will be crawling down their throat to fix the problems....and at least the toxicity would improve. It's way more painful to a residency to reply to those surveys and having educators examining your every crevasse, then to improve the lives of the residents.

 

[thecarbonionangle]

Trusting that a top tier program will pick up residents from a failing program is wishful thinking in rad onc. what is more likely to happen is for them to be screwed. Also acgme survey is a bunxh if numbers with zero room for typing out anything

 

[GreyingRadOnc]

Trusting that a top tier program will pick up residents from a failing program is wishful thinking in rad onc. what is more likely to happen is for them to be screwed. Also acgme survey is a bunxh if numbers with zero room for typing out anything

The numbers are what kill you. They compare it to national averages and just like your oil change, only a perfect score is acceptable. At my institution, if you don't score in the 90th percentile the Dean will require a detailed analysis of what went wrong and what you will do to change it. Any precipitous drop results in a "special session" where the dean calls in the residents, without the PD present and quizzes them about what's wrong. That's followed by a meeting with the dean and your chair must be present. Colon preps are less painful.

I don't know what would happen if a program failed. It hasn't happened in the modern era (to my knowledge). My point is that the survey is a powerful tool residents have immediately available to them if they feel the program is malignant.

 

[GreyingRadOnc]

One problem is that there is no free text on those ACGME surveys. Just 1 through 5 "agree strongly" "disagree strongly", which is neither nuanced nor helpful to anyone. If there was a free text form on the ACGME surveys, let's just say a long thesis would leave my fingertips and go into the ether, consequences be damned.

You can also write the ACGME directly. I mentored a nice resident in another specialty and his program was treating him horribly. I advised him to write it up, with details, and submit it to his dean and the ACGME. He got immediate attention. The ACGME has a nice tool...I can't post links, but if you google ACGME report an issue you'll find it.

 

[thecarbonionangle]

Things are not anonymous. People have posted in past about getting ACGME involved and ending up in programs bad side when they found out. Its a very small filled with petty, insecure, manipulative people. I don’t share any faith in the system you have. The dean calls in residents as a show. These people just want to identify problem residents then tell the chair

 

[deleted18755]

ok so a resident ( or residents) in said program fill out survey and are honest, and either get their program shut down or get it on probation, then look for a job coming from a program on probation and nobody gives them a job, because who would want to employ people from such a horrible program on probation. There is no mechanism to take care of these residents who are doing something for the good of their program or the specialty. what place will employ them? which program will take them if they get their program shut down? if you really want people to be honest in the survey you need to give them an out. I don't think people in these programs answer honestly for these reasons.

Sadly, this was my first thought. Can you imagine trying to compete with dozens of other applicants for a job coming from a program that is known to be on probation or closed? The first thing the employer would think is that this resident received sub-optimal training, which unfortunately and at no fault of the resident very well may be the case, but in any case with so many applications why take the chance on this "red flagged" applicant?

I would hope that this isn't the case but given how small this field and how competitive jobs are getting I wouldn't blame a resident for just sucking it up, taking education into ones hands, and trying to pass boards and get on with ones life vs doing the right thing. Such a sad situation.

I'm increasingly far from academics and residency training but in my (limited) experience the worst situations are when you have senior faculty ("experts") with a relatively less senior or "powerful" chair who caters to every one of the senior faculty demands vs the resident education.

 

[GreyingRadOnc]

Things are not anonymous. People have posted in past about getting ACGME involved and ending up in programs bad side when they found out. Its a very small filled with petty, insecure, manipulative people. I don’t share any faith in the system you have. The dean calls in residents as a show. These people just want to identify problem residents then tell the chair

Well, I can only assure you this isn't true. As you may have guessed I've been involved with resident education at poitns and our program has had less than stellar surveys on occasion. The dean and program took a very hard and long look at the program and required several changes. Honestly, they were all good changes and resulted in better education. I never had any idea who said what to whom. If I had "retaliated" I would have immediately been taken out as PD. It's not in the best interest of the PD to retaliate. Moreso it's in the best interest of the PD to make the program as resident friendly as possible, regardless of what you may think about the changes. It's not exclusive to my GME either. I referenced helping a resident out who was being treated badly in another speciality, at another GME. And by bad I mean rascist, personal comments including too fat, bad breath, and not smart enough to match in a fellowship. That kind of bad. He went to his dean with documentation and they stopped all the bullying. They don't love him, or treat him well, but they didn't bully him and he matched to his chosen fellowship (ie didn't retaliate).

Lastly, I would say the chances that a outside private practice or satellite would know about the probation of a residency program is nil. Even as a PD, I know programs were probably on probation, but it was never public. What's annoying is how badly worded the survey is, which leads to confusion by the residents. There's a consensus on this board and possibly in the larger Rad Onc community that there's too many residency slots/programs. If no one complains leading to probation and eventual closure how else would the community shrink?

 

[evilbooyaa]

If no one complains leading to probation and eventual closure how else would the community shrink?

I agree with you that residents SHOULD mention any especially glaring deficiencies of the program on the annual survey. Not to say that the concerns about retaliation are overblown, but I imagine the culture is different from instititution to institituion. Some places are like "anybody have suggestions on how to improve the program?" and others are "this is how it is don't ask questions or complain, millenial". It's hard sometimes because, as a resident, I kind of go "well I mean this could be better but it's not going to affect me long term and is it really worth creating a stink over" - different from "omg this program sucks I'm a scut monkey and I'm not learning anything and nobody respects me". If it was the latter, I'd probably put negative things on the survey. In the former situation I just leave it as positive.

One method that has been proposed is to vastly increase the requirements for advanced technology (SRS/SBRT) at a minimum, probably brachy, potentially pediatrics compared to the laughably low levels they are now. Programs may not close per se but may have to at least constrict in size to meet the new requirements. If there's 8 peds solid tumor cases a year and you need 8 to graduate, you can have 2 residents a year. If you make the number to graduate 16, the program will have to contract to 1 resident per year. If there's 10 interstitials a year and you need 5 to graduate, that's 4 residents a year. You up that to 10 needed to graduate, bam that's down to 2 residents a year.

There should be consideration of a limit to how many 'sites' a resident can be shipped off too. As an attending involved in resident education, is it valuable to go to 4 or more sites (mandatorily, outside of elective time) as a resident, or is it essentially getting scutted out?

The ability to do 350 palliative cases for your EBRT experience and graduate residency is laughable. No requirements for any definitive cases. No minimum number of H&N or Pelvis or non-SRS CNS. The ability to do only vaginal cylinders without doing a single T&O for definitive cervix is laughable. At least they made it so that IORT couldn't be considered 'interstitial brachytherapy' so that's a plus otherwise we'd have residents having not done a single PSI/HDR Prostate OR a Syed/Vienna.

 

[GreyingRadOnc]

I agree with you that residents SHOULD mention any especially glaring deficiencies of the program on the annual survey. Not to say that the concerns about retaliation are overblown, but I imagine the culture is different from instititution to institituion. Some places are like "anybody have suggestions on how to improve the program?" and others are "this is how it is don't ask questions or complain, millenial". It's hard sometimes because, as a resident, I kind of go "well I mean this could be better but it's not going to affect me long term and is it really worth creating a stink over" - different from "omg this program sucks I'm a scut monkey and I'm not learning anything and nobody respects me". If it was the latter, I'd probably put negative things on the survey. In the former situation I just leave it as positive.

One method that has been proposed is to vastly increase the requirements for advanced technology (SRS/SBRT) at a minimum, probably brachy, potentially pediatrics compared to the laughably low levels they are now. Programs may not close per se but may have to at least constrict in size to meet the new requirements. If there's 8 peds solid tumor cases a year and you need 8 to graduate, you can have 2 residents a year. If you make the number to graduate 16, the program will have to contract to 1 resident per year. If there's 10 interstitials a year and you need 5 to graduate, that's 4 residents a year. You up that to 10 needed to graduate, bam that's down to 2 residents a year.

There should be consideration of a limit to how many 'sites' a resident can be shipped off too. As an attending involved in resident education, is it valuable to go to 4 or more sites (mandatorily, outside of elective time) as a resident, or is it essentially getting scutted out?

The ability to do 350 palliative cases for your EBRT experience and graduate residency is laughable. No requirements for any definitive cases. No minimum number of H&N or Pelvis or non-SRS CNS. The ability to do only vaginal cylinders without doing a single T&O for definitive cervix is laughable. At least they made it so that IORT couldn't be considered 'interstitial brachytherapy' so that's a plus otherwise we'd have residents having not done a single PSI/HDR Prostate OR a Syed/Vienna.

If the SABR-COMET trials in Phase III come back positive that may happen. They did increase the number of SBRT required this past year (I don't remember to what, however). I think the other idea about having people rotate away is a good one. Most GMEs hate sending residents out since they pay the salary/benefits for those months, but loose the help. I would say that the data also may support requiring sufficient cases for 2 residents/year given how badly small programs did on written boards. That was sad to see, as those residents already face so many challenges. I know there's some feeling that having dedicated RadBio and Physics staff on site would help too. Ultimately that falls to the ACGME and RRC to decide/implement.

 

[CptCrunch]

Well, I can only assure you this isn't true. As you may have guessed I've been involved with resident education at poitns and our program has had less than stellar surveys on occasion. The dean and program took a very hard and long look at the program and required several changes. Honestly, they were all good changes and resulted in better education. I never had any idea who said what to whom. If I had "retaliated" I would have immediately been taken out as PD. It's not in the best interest of the PD to retaliate. Moreso it's in the best interest of the PD to make the program as resident friendly as possible, regardless of what you may think about the changes. It's not exclusive to my GME either. I referenced helping a resident out who was being treated badly in another speciality, at another GME. And by bad I mean rascist, personal comments including too fat, bad breath, and not smart enough to match in a fellowship. That kind of bad. He went to his dean with documentation and they stopped all the bullying. They don't love him, or treat him well, but they didn't bully him and he matched to his chosen fellowship (ie didn't retaliate).

I applaud the efforts in your program to incorporate resident feedback and criticism, but I don't see how you can generalize that to all residency programs. With many programs having 4-8 total residents, the cloak of anonymity attached to the ACGME survey seems distressingly thin. I agree that in an ideal world a resident would be able to answer truthfully without fear of retaliation, but unfortunately I don't think that's realistically the case.

Lastly, I would say the chances that a outside private practice or satellite would know about the probation of a residency program is nil. Even as a PD, I know programs were probably on probation, but it was never public. What's annoying is how badly worded the survey is, which leads to confusion by the residents. There's a consensus on this board and possibly in the larger Rad Onc community that there's too many residency slots/programs. If no one complains leading to probation and eventual closure how else would the community shrink?

The ACGME publicly releases accreditation status for all residency programs on their website (ACGME - Accreditation Data System (ADS)). They don't archive the information, but current status is absolutely public information.

 

[GreyingRadOnc]

I applaud the efforts in your program to incorporate resident feedback and criticism, but I don't see how you can generalize that to all residency programs. With many programs having 4-8 total residents, the cloak of anonymity attached to the ACGME survey seems distressingly thin. I agree that in an ideal world a resident would be able to answer truthfully without fear of retaliation, but unfortunately I don't think that's realistically the case.

The ACGME publicly releases accreditation status for all residency programs on their website. They don't archive the information, but current status is absolutely public information.

It's challenging in a very small program. I agree. I've been in programs with 8 and there's a fair degree of anonymity with serious problems, but probably not with 4. I don't think most places look at that before hiring if they like the person. I say that because they rarely call the staff and even ask how they were as a resident, which is way more useful to know prior to hiring.

 

[CptCrunch]

Trusting that a top tier program will pick up residents from a failing program is wishful thinking in rad onc. what is more likely to happen is for them to be screwed. Also acgme survey is a bunxh if numbers with zero room for typing out anything

I remember the Drexel/Hahnemann program closed a few years ago (maybe 5-ish?). I believe their residents at the time were absorbed by other programs, maybe not necessarily "top" programs, but they were able to continue their training.

 

[medgator]

Even as a PD, I know programs were probably on probation, but it was never public.

False.

As a med student and resident, I distinctly recall a public acgme website being available to look up programs on probation in every specialty. In fact, I recall seeing programs like Drexel and Howard on probation while I was in training (both of which went on to be shut down).

Are you seriously a PD? If so, how were you unaware such information was public knowledge? In addition to your commentary on the job market, this statement really makes me question your credibility as a "PD"

 

[fiji128]

Please provide advice for residents in such programs. How did you navigate it? There are people reading who may find this useful.
There are attendings in some places who have no idea how to even do IMRT and need full coverage because everyone knows they are unsafe and must be watched at all times. Some of them are even “big names”. I find these situations sad. What can residents even do without harming their program and getting it shut down? I dont understand how in some places it can be acceptable to have effectively zero education.

I was at a smaller program. I filled out these ACGME survey as truthfully as possible and encouraged the other residents to do so as well. The result was after a few years of declining survey scores the program has to formerly reply to ACGME as why they thought the scores were declining but nothing really happened from a practical stand point just a lot of hand waving. This did not make the Chair and PD happy and they did there best to retaliate. My impression of the whole thing was the ACGME is not there for residents but rather to protect programs at the end of the day unless something really crazy is going on. The problem was that both the Chair and PD were not interested in running the best residency program they could just one that would require the least amount of work on their part. I doubt this is unique to my former program. At the end of the day the only thing they seemed to take seriously is the pass rate on the board exams. Everyone from my program has passed everything for about the last 10 years including this year's rad bio/physic. But this was more of a function of self study then formal instruction from the residency program.

 

[GreyingRadOnc]

False.

As a med student and resident, I distinctly recall a public acgme website being available to look up programs on probation in every specialty. In fact, I recall seeing programs like Drexel and Howard on probation while I was in training (both of which went on to be shut down).

Are you seriously a PD? If so, how were you unaware such information was public knowledge? In addition to your commentary on the job market, this statement really makes me question your credibility as a "PD"

It's public, but no one is paying attention to it. I have never looked at that web site. Maybe employers check it but I seriously doubt it....they rarely call and ask questions about the residents let alone follow up on those elements. So, yes it's public, but I haven't seen it impact anyone adversely. Ex: in another post I mentioned a resident I mentored that ran afoul of his small program and he complained to the dean. That program is on probation, but he still matched to a competitive fellowship.

 

[GreyingRadOnc]

I was at a smaller program. I filled out these ACGME survey as truthfully as possible and encouraged the other residents to do so as well. The result was after a few years of declining survey scores the program has to formerly reply to ACGME as why they thought the scores were declining but nothing really happened from a practical stand point just a lot of hand waving. This did not make the Chair and PD happy and they did there best to retaliate. My impression of the whole thing was the ACGME is not there for residents but rather to protect programs at the end of the day unless something really crazy is going on. The problem was that both the Chair and PD were not interested in running the best residency program they could just one that would require the least amount of work on their part. I doubt this is unique to my former program. At the end of the day the only thing they seemed to take seriously is the pass rate on the board exams. Everyone from my program has passed everything for about the last 10 years including this year's rad bio/physic. But this was more of a function of self study then formal instruction from the residency program.

I'm very sorry to hear that. I haven't experienced it that way....sorry that others aren't taking that part of the job seriously. Those programs don't belong and it's a shame that it compromised your education. Most of the programs I've interacted with have been very dedicated to resident education and training.

 

[thecarbonionangle]

I was at a smaller program. I filled out these ACGME survey as truthfully as possible and encouraged the other residents to do so as well. The result was after a few years of declining survey scores the program has to formerly reply to ACGME as why they thought the scores were declining but nothing really happened from a practical stand point just a lot of hand waving. This did not make the Chair and PD happy and they did there best to retaliate. My impression of the whole thing was the ACGME is not there for residents but rather to protect programs at the end of the day unless something really crazy is going on. The problem was that both the Chair and PD were not interested in running the best residency program they could just one that would require the least amount of work on their part. I doubt this is unique to my former program. At the end of the day the only thing they seemed to take seriously is the pass rate on the board exams. Everyone from my program has passed everything for about the last 10 years including this year's rad bio/physic. But this was more of a function of self study then formal instruction from the residency program.

People are successful despite their programmes
Absolutely! The deans job is to keep programme open. They want to avoid their programme shut down under their watch. Many programmes operate like this these days; to work in ways to do less work rather than benefit of the programme