USMLE Forum Archives - The Match & Residency - About Radiation Oncolgy Residency
About Radiation Oncolgy Residency
adonis123 - 12-13-10 02:30
What is Radiation Oncology?
Overview
To simplify a bit, Radiation Oncology encompasses the selection, treatment, management, and follow-up of patients treated with ionizing radiation. Though the vast majority of what we treat is "cancer" (either benign or malignant) we also treat conditions such as trigeminal neuralgia, keloids, Grave's ophthalmopathy, and even medically refractory psychiatric disorders.
The three big cancers that we treat are breast, prostate, and lung cancer. Other major cancers include head and neck (oral cavity, oropharynx, larnyx, hypopharynx, thyroid), GI (esophagus, gastric, pancreatic, rectal, anal), GU (bladder, penile), CNS (glioma, meningioma, brain mets), and lymphoma.
Training
After medical school we all do one year of "general" something. This is generally an internal medicine or transitional year. Other options include general surgery, pediatrics, or family medicine. Following this we do four years of clinical radiation oncology. One of the unique features of our residency compared to other oncology fellowships (Surgical Oncology, Medical Oncology, etc.) is that we have the most years of "pure" oncologic training.
A Typical Week
Everyone's day is different of course but a typical week generally includes new patient consults, on-treatment visits (where patients you are treating with radiation see you to manage side effects), follow-up visits (for patients who have completed treatment), simulations (where you set up patients for radiation treatments), treatment planning (where you delineate your radiation targets on imaging), and research.
Technology
One of the perks of this field (especially to all you tech-philes) is the rapidly advancing technology. Back in the day we used to use machines with radioactive cobalt to treat patients (note that very few places in the US and many developing countries still have these). Cobalt machines have been supplanted nowadays with linear accelerators which generate photons electrically. These have the benefit of having an on-off switch (you can't "turn off" radioactive decay), multiple beam energies, and more accurate field shaping.
There are many other modalities including radiosurgery (basically delivering very high radiation doses to relatively small areas) which can be administered by a variety of methods including a Gamma Knife, Cyber Knife, or by a specially adapted linear accelerator (e.g. Varian Triology). Protons are also available in an increasingly large number of centers which have some advantages over photons in terms of dose distribution.
Finally, there is brachtherapy which is the insertion of radioactive sources near (intracavitary) or inside (interstitial) a tumor. There are many ways to deliver this either using permanent implants such as I-125 or Pd-103 or high-dose rate temporary implants like Ir-192.
Applying to Rad Onc
What are the average Step I scores?
For the 2008 application cycle the mean Step I score was 238 with a standard deviation of around 229-249.
Source: http://www.nrmp.org/data/chartingoutcomes2009v3.pdf
But my Step I scores are nowhere near that? Am I screwed?
Not necessarily. The beauty of applying to Rad Onc is that Step I scores are not the be-all, end-all like Dermatology or Integrated Plastics. By way of example, in 2008 three US Seniors matched with Step I scores in the 191-200 range and four matched in the 201-210 range. Obviously, these individuals had other aspects to their application that were favorarble like high clinical grades, good research, and/or interesting backgrounds.
Everyone says research is critical . . . is this true?
Yes, this is absolutely correct. In 2008 the mean number of abstracts, publications, and presentations for US seniors was 8. The number of MD/PhDs who matched were about 22% of the total applicant pool. Only 5% of applicants who matched had ZERO abstracts, publications, and presentations.
So what are residency directors looking for?
Two things which distinguish Rad Onc from other fields are the importance of research (see above) and letters of recommendation. Rad Onc is a small field and strong letters from heavy hitters in the field carry weight in admissions. Other important factors are strong clinical grades and good Step I scores (see above). Based on some applicants' experiences, it appears that volunteer work is not as highly prized as some other fields.
OK . . . research is key I get it. But what kind of research?
Painting with a broad brush basic (translational) > clinical > physics. Conversely (again over-simplifying a bit), the level of effort to get abstracts/publications/presentations is roughly ordered physics > clinical > basic (translational). If you have a lot of time on your hands (interested in Rad Onc as an MS-1 or MS-2) then it's good to throw a wide net and work on multiple projects. You never know which research projects will go bust and which will be high yield. Nothing looks worse than a year or more of research without the requisite publication (or abstract) to show for it . . . it makes you look like a slacker. Ideally, the research should be in Radiation Oncology but the exception is if you are doing a PhD or HHMI/DD. In those cases, basic research applicable to cancer is fine. If you do research in an area completely unrelated to cancer it may not help you very much . . . mainly because most Rad Onc attendings on admissions committess are not sophisticated enough to figure out what you actually did.
Preliminary Medicine/Surgery year or Transitional year for internship?
First off, the titles "Preliminary" year and "Transitional" year have quite a bit of institutional variablity so let me be a bit more precise in my definition. A traditional "Preliminary" year consists predominantly of several general medicine ward months, a couple of sub-speciality medicine ward months, a month or so of ICU, a month or so of ambulatory medicine (or ER), and perhaps a month of elective. A traditional "Transitional" year consists of a couple of general medicine ward months, a couple of general surgery ward months, and a whole lot of electives. Generally Transitional > Preliminary as far as being cush goes. However, you should do what you prefer as it makes little difference to a practicing Radiation Oncologist. The benefits of a "Preliminary" year are practicing "real" medicine and prestige whereas the benefits of a "Transitional" year are the diversity of clinical experiences that you get. If a program director asks you what you want to do, 9 times out of 10 the answer they are looking for is "I am doing a preliminary medicine or surgery year in an academic medical center." Otherwise, it may make you look like a slacker. When rank list time comes however, rank whatever you want of course . . .
Can a DO or FMG get into Rad Onc?
Yes and yes, it happens every year. However, the road is difficult. I can tell you honestly that DO and FMG candidates who are seriously considered for Rad Onc are superior to the average MD candidate. The reason for this is, of course, the preceived stigma of being a DO or FMG in the first place. In addition to copious amounts of research, you should work in a Rad Onc department (preferably the one you are most interested in) to generate face time and make connections. And YES I am aware that Paul Wallner DO is a diety in our field and an ASTRO Gold Medal winner. However, you are not Paul Wallner.
Should I schedule away electives?
Absolutely, yes! Even if you are a MS at a top-notch program it will help you to do away rotations provided that you (1) do not have a toxic personality and (2) you are willing to work hard and (3) you are not an ass-kisser [trust me, we notice and we don't like it]. If you have a strong home Rad Onc program (obviously strong means that you at least have a residency program) then one away is sufficient. If you don' t have a home program or if your home program is not taking applicants your year then two aways is a good idea. If you do two, generally one should be at a program that you feel you have a reasonable chance of getting into and the second should be at a "reach" place to procure good letters of recommendation.
I am in college/high school/middle school/elementary school/kindergarten/in utero and am REALLY interested in Rad Onc!! Is there anything I can do now to prepare myself
Jumping the gun a little bit are we? The most important thing to do is to enjoy yourself at your current level of training and do all the hobbies and activities that you always wanted to try. To get into Rad Onc one of the most important factors is to get into a medical school that has a strong Rad Onc department. However, there are so many other more important, relevant factors when choosing medical school: the tuition (and how much you get in the way of grants/scholarships), the curriculum, the location, the students, the faculty, etc. etc. Besides, most people who want to go into a field end up changing their mind. I always wanted to be a Neurosurgeon but that ended the day my 3rd year Surgery rotation started. Still, the simple fact that you are even aware of the existence of this field puts you ahead of many medical students.
What are good books for medical students doing Rad Onc rotations?
The top two books for residents and med students are:
1. The Hansen/Roach Handbook
2. The Haffty/Wilson Handbook
You should peruse each and determine which complements your learning style best.
adonis123 - 12-13-10 02:30
What is Radiation Oncology?
Overview
To simplify a bit, Radiation Oncology encompasses the selection, treatment, management, and follow-up of patients treated with ionizing radiation. Though the vast majority of what we treat is "cancer" (either benign or malignant) we also treat conditions such as trigeminal neuralgia, keloids, Grave's ophthalmopathy, and even medically refractory psychiatric disorders.
The three big cancers that we treat are breast, prostate, and lung cancer. Other major cancers include head and neck (oral cavity, oropharynx, larnyx, hypopharynx, thyroid), GI (esophagus, gastric, pancreatic, rectal, anal), GU (bladder, penile), CNS (glioma, meningioma, brain mets), and lymphoma.
Training
After medical school we all do one year of "general" something. This is generally an internal medicine or transitional year. Other options include general surgery, pediatrics, or family medicine. Following this we do four years of clinical radiation oncology. One of the unique features of our residency compared to other oncology fellowships (Surgical Oncology, Medical Oncology, etc.) is that we have the most years of "pure" oncologic training.
A Typical Week
Everyone's day is different of course but a typical week generally includes new patient consults, on-treatment visits (where patients you are treating with radiation see you to manage side effects), follow-up visits (for patients who have completed treatment), simulations (where you set up patients for radiation treatments), treatment planning (where you delineate your radiation targets on imaging), and research.
Technology
One of the perks of this field (especially to all you tech-philes) is the rapidly advancing technology. Back in the day we used to use machines with radioactive cobalt to treat patients (note that very few places in the US and many developing countries still have these). Cobalt machines have been supplanted nowadays with linear accelerators which generate photons electrically. These have the benefit of having an on-off switch (you can't "turn off" radioactive decay), multiple beam energies, and more accurate field shaping.
There are many other modalities including radiosurgery (basically delivering very high radiation doses to relatively small areas) which can be administered by a variety of methods including a Gamma Knife, Cyber Knife, or by a specially adapted linear accelerator (e.g. Varian Triology). Protons are also available in an increasingly large number of centers which have some advantages over photons in terms of dose distribution.
Finally, there is brachtherapy which is the insertion of radioactive sources near (intracavitary) or inside (interstitial) a tumor. There are many ways to deliver this either using permanent implants such as I-125 or Pd-103 or high-dose rate temporary implants like Ir-192.
Applying to Rad Onc
What are the average Step I scores?
For the 2008 application cycle the mean Step I score was 238 with a standard deviation of around 229-249.
Source: http://www.nrmp.org/data/chartingoutcomes2009v3.pdf
But my Step I scores are nowhere near that? Am I screwed?
Not necessarily. The beauty of applying to Rad Onc is that Step I scores are not the be-all, end-all like Dermatology or Integrated Plastics. By way of example, in 2008 three US Seniors matched with Step I scores in the 191-200 range and four matched in the 201-210 range. Obviously, these individuals had other aspects to their application that were favorarble like high clinical grades, good research, and/or interesting backgrounds.
Everyone says research is critical . . . is this true?
Yes, this is absolutely correct. In 2008 the mean number of abstracts, publications, and presentations for US seniors was 8. The number of MD/PhDs who matched were about 22% of the total applicant pool. Only 5% of applicants who matched had ZERO abstracts, publications, and presentations.
So what are residency directors looking for?
Two things which distinguish Rad Onc from other fields are the importance of research (see above) and letters of recommendation. Rad Onc is a small field and strong letters from heavy hitters in the field carry weight in admissions. Other important factors are strong clinical grades and good Step I scores (see above). Based on some applicants' experiences, it appears that volunteer work is not as highly prized as some other fields.
OK . . . research is key I get it. But what kind of research?
Painting with a broad brush basic (translational) > clinical > physics. Conversely (again over-simplifying a bit), the level of effort to get abstracts/publications/presentations is roughly ordered physics > clinical > basic (translational). If you have a lot of time on your hands (interested in Rad Onc as an MS-1 or MS-2) then it's good to throw a wide net and work on multiple projects. You never know which research projects will go bust and which will be high yield. Nothing looks worse than a year or more of research without the requisite publication (or abstract) to show for it . . . it makes you look like a slacker. Ideally, the research should be in Radiation Oncology but the exception is if you are doing a PhD or HHMI/DD. In those cases, basic research applicable to cancer is fine. If you do research in an area completely unrelated to cancer it may not help you very much . . . mainly because most Rad Onc attendings on admissions committess are not sophisticated enough to figure out what you actually did.
Preliminary Medicine/Surgery year or Transitional year for internship?
First off, the titles "Preliminary" year and "Transitional" year have quite a bit of institutional variablity so let me be a bit more precise in my definition. A traditional "Preliminary" year consists predominantly of several general medicine ward months, a couple of sub-speciality medicine ward months, a month or so of ICU, a month or so of ambulatory medicine (or ER), and perhaps a month of elective. A traditional "Transitional" year consists of a couple of general medicine ward months, a couple of general surgery ward months, and a whole lot of electives. Generally Transitional > Preliminary as far as being cush goes. However, you should do what you prefer as it makes little difference to a practicing Radiation Oncologist. The benefits of a "Preliminary" year are practicing "real" medicine and prestige whereas the benefits of a "Transitional" year are the diversity of clinical experiences that you get. If a program director asks you what you want to do, 9 times out of 10 the answer they are looking for is "I am doing a preliminary medicine or surgery year in an academic medical center." Otherwise, it may make you look like a slacker. When rank list time comes however, rank whatever you want of course . . .
Can a DO or FMG get into Rad Onc?
Yes and yes, it happens every year. However, the road is difficult. I can tell you honestly that DO and FMG candidates who are seriously considered for Rad Onc are superior to the average MD candidate. The reason for this is, of course, the preceived stigma of being a DO or FMG in the first place. In addition to copious amounts of research, you should work in a Rad Onc department (preferably the one you are most interested in) to generate face time and make connections. And YES I am aware that Paul Wallner DO is a diety in our field and an ASTRO Gold Medal winner. However, you are not Paul Wallner.
Should I schedule away electives?
Absolutely, yes! Even if you are a MS at a top-notch program it will help you to do away rotations provided that you (1) do not have a toxic personality and (2) you are willing to work hard and (3) you are not an ass-kisser [trust me, we notice and we don't like it]. If you have a strong home Rad Onc program (obviously strong means that you at least have a residency program) then one away is sufficient. If you don' t have a home program or if your home program is not taking applicants your year then two aways is a good idea. If you do two, generally one should be at a program that you feel you have a reasonable chance of getting into and the second should be at a "reach" place to procure good letters of recommendation.
I am in college/high school/middle school/elementary school/kindergarten/in utero and am REALLY interested in Rad Onc!! Is there anything I can do now to prepare myself
Jumping the gun a little bit are we? The most important thing to do is to enjoy yourself at your current level of training and do all the hobbies and activities that you always wanted to try. To get into Rad Onc one of the most important factors is to get into a medical school that has a strong Rad Onc department. However, there are so many other more important, relevant factors when choosing medical school: the tuition (and how much you get in the way of grants/scholarships), the curriculum, the location, the students, the faculty, etc. etc. Besides, most people who want to go into a field end up changing their mind. I always wanted to be a Neurosurgeon but that ended the day my 3rd year Surgery rotation started. Still, the simple fact that you are even aware of the existence of this field puts you ahead of many medical students.
What are good books for medical students doing Rad Onc rotations?
The top two books for residents and med students are:
1. The Hansen/Roach Handbook
2. The Haffty/Wilson Handbook
You should peruse each and determine which complements your learning style best.
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#1
Re: About Radiation Oncolgy Residency
adonis123 - 12-13-10 02:34 Questions about the field of Rad Onc
Isn't Rad Onc a dying field?
I try hard not to laugh when I hear this question. For one, NOBODY CAN PREDICT THE FUTURE. Secondly, someone in a field is unlikely to admit to an anonymous person on the Internet his field is dying (even if it is!). Third, the question belies a strong (albeit understandable, you ARE reading this FAQ ) ignorance of this field. My friends, long gone are the days when you took a piece of radioactive cobalt, suspended it over a patient, crudely drew out a treatment field (e.g. "right lung field," "pancreas field," "brain field," etc) and pulled the patient away when you thought he was irradiated sufficiently. Nowadays we are in the era of robotic radiosurgery, linear accelerators delievering multiple/dynamic/conformal arcs, and proton-producing machines that can sit on a table top. Impressed you, eh? I love writing a progress note that reads, "your inpatient was treated by dose-painted intensity-modulated radiation therapy using nine non-opposed coplanar beams using combined 6 mV/18 mV photon energies. The gross tumor volume is receiving 7200 cGy in 33 fractions prescribed to the 88% isodose line." Their reaction is priceless!
But I digress . . .
Radiation Oncology is an evolving field and as such has areas which are dying off and areas which are emerging. For example, our steroetactic body radiosurgery machines are capable of controlling early-stage lung cancer just as well as a thoracic surgeon's lobar resection . . . a fact that does not endear us to them. On the other hand we have turf wars with Nuclear Medicine and Medical Oncology about delivering radio-iostope conjugated antibodies.
Furthermore, Radiation Oncology is a complementary modality with Surgical Oncology and Medical Oncology. Many disease (advanced head & neck cancers, advanced lung cancers, many primary brain tumors) require all three modalities for standard of care. In some cases radiation alone is perfectly sufficient (early stage larynx cancer, early stage prostate cancer, brain metastases). In other cases radiation is not generally indicated (most stages of colon cancer). The technology is improving all the time. I can confidently say that the field will be much different 20 years from now than it is today because of technology/scientific advancement. But dying? Pish-posh.
Isn't all that radiation exposure bad for you?
Well if I decided to see my on-treatment patients WHILE THE MACHINE WAS ON, this might be a problem. But you see, state and federal regulatory agencies have this "thing" about unecessarily irradiating bystanders near treatment vaults. You know that most treatment machines are in the basement right? Well if Uncle Joe was buying a gift for his niece in the gift shop, I don't think he would appreciate being irradiated with the 2.12 Gy that Ms. Sullivan was recieving downstairs. So we have lead and concrete shielding, and massive vault doors made of borated polyethylene to prevent just such incidents. Also, the radiation therapists are the ones who actually operate the machines and position the patients giving you another "layer" of protection. Finally we all wear dosimetry film badges which are carefully audited for exposure. All in all I would say we actually have significantly LESS exposure then fields like interventional cards/rads where they use radiation with fluoroscopic abandon.
What are the salaries like?
Coming out of residency, your salary will vary wildly depending upon (a) practice environment, (b) location in the country, and (c) other miscellaneous factors. As a general rule, 1st year attending salaries tend to range between $180,000 - $350,000. I'd say about 90% of salaries fall into that range. You can get an even higher salary if you sacrifice your autonomy and/or dignity (i.e. urorads). Generally speaking for pure academic jobs (tenure-track faculty position) and pure private practice jobs (the partners own the equipment & facilities) your salaries will be comparable to start -- probably in the $200,000 - $250,000 range. However once you make partner in a pure private practice set-up your salary will be boosted significantly ($400,000+) depending on how much revenue your practice generates. If you work in a private hospital and receive a salary (i.e. Kaiser), your starting pay will tend to be higher (~$300,000) but will not go up very much with seniority.
The Holman Pathway
What is the Holman Pathway?
For a full description click here.
Briefly, the Holman Pathway is an option offered to Radiation Oncology residents by The American Board of Radiology (ABR). The ABR is responsible for granting board eligibility, board certificaiton, and maintenance of certification to all Radiation Oncology residents/faculty in the United States. The Holman Pathway is an option for residents who are highly motivated and qualified for academic careers. It allows you to perform 18-21 months of research during your residency (80% research & 20% clinical during the pathway months) without increasing the total length of your residency. In other words, it allows you to do abbreviated clinical training and substitute it with a qualified research project. To apply you need the full support of your Chair, Program Director and potential mentor and need to write up a brief application specifiying your aims and containing letters of support from the aforementioned individuals.
Is it difficult to obtain the Holman Pathway? If so, why?
It depends how you define "difficult." If your definition is the number of applicants accepted into the Holman pathway divided by the number who apply then the answer is no, it is not difficult as the value is close to 1.0.
If you define "difficult" as (a) matching at a residency that is actually receptive to residents doing the Holman pathway (very few), (b) finding a mentor who is willing to take you on, (c) having a residency that is willing to tackle the hardships of having a resident mostly out of the clinic for 18-21 months then the answer is yes, it is difficult to get all of your ducks in a row.
I imagine it is more troublesome to assimilate the Radiation Oncology knowledge base when faced with other committments, to what extent is this true? Do you think the Holman pathway detracts from clinical competency?
This is a controversial question. If you ask non-Holman residents (the vast majority of Rad Onc residents) the answer to them would be an obvious "yes it detracts from your clinical competency." Maybe even, "hell yes! It detracts from your clinical competency."
As a resident who has completed the Holman pathway, who has talked to other residents going through it at other institutions, and directly interacted with faculty who completed it I'd say, "in the short term it may detract from your clinical competency, but in the end you will be as competent." My reasons for this are (a) you have to be above average as deemed by your PD and Chair to enter the Holman pathway in the first place and (b) people who do Holman tend to be aggressively "beef up" their clinical knowledge base in the last year or so of residency.
I noted a requirement for 21 months of research time... Is there a requirement for the number of publications that should be generated during this time?
First off the research time can be as short as 18 months and still qualify for Holman. Second, when you apply to the Holman pathway you are simply asking the ABR to allow you to remain board eligible in Radiation Oncology with abbreviated clinical training for the purposes of meritorious research. That's it, nothing more and nothing less. The ABR relies heavily on your PD, Chair and mentor to ensure that you are qualifed to do Holman and only vetoes your application in unusual circumstances. There are no requirements once you are in the Holman pathway other than submitting annual progress reports to the ABR.
#2
Re: About Radiation Oncolgy Residency adonis123 - 12-13-10 02:39 1. All oncology patients are referred to RadOnc. Therefore, it is best to have cordial relationships with other oncologists and surgeons.
2. At the initial consultation the patient is seen by the attending (sometimes preceded by resident and/or med student). At this time, the attending takes a full history and physical. Prior to the consult, appropriate labs, films, and medical history are reviewed. The attending gives the pt options and we go to the next step if pt wants to proceed with radiotherapy. The choice of treatment depends on what the current literature says, institutional hardware, and the attending's own experiences.
3. Pt is "simmed." Rad techs position the patient in the machine and "simulate" an actual treatment. This way attending can verify the regional anatomy (both bony landmarks and soft tissue critical structures) and make adjustments as necessary.
4. Pt is "planned." Now that the images are on disk, the patient's tumor volumes and critical structures are "contoured" by the resident and/or attending. Once the attending is satisfied with the area covered by radiation (including extra margins for tumor not apparent on imaging) then the plan goes to the dosimetrists.
5. Dosimetrists (w/ or w/o resident) calculates plan including beam angles, doses, and fractionation. Generally, there is some degree of back and forth b/w the attending and dosimetrist with regard to plan optimization. Physics also looks at the plan and approves it.
6. Pt is brought back for first treatment. Everything is set-up and pt is "simmed" one more time to ensure quality treatment. If everything looks good, pt receives first treatment.
7. During the course of treatment pt receives so called "portal films." (usually 1/week) These are images taken with the treatment machine to verify that you are actually irradiating the correct area. Also, patients see the attendings to report any side-effects or if they have any questions 1/week or so -- though obviously immediately for pressing issues.
8. Pt is seen @ follow-up clinics periodically for up to several years post-RT. Generally, the attending reviews scans to evaluate recurrence of disease as well as a physical exam.
That's more or less the sequence.
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