Residency Review Committee for Radiation Oncology

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Residency Review Committee for Radiation Oncology

  1. 1. Residency Review Committee for Radiation Oncology FREQUENTLY ASKED QUESTIONS PLEASE NOTE: Effective July 1, 2006, all requests for temporary increases in the resident complement must be submitted via the ADS system. To access this data system, please log on to the ACGME’s website: www.acgme.org NEW UNSEALED SOURCE REQUIREMENT Why do residents now have to participate in unsealed source procedures? How many “unsealed” sources are required to be performed by the resident? Does administration of radioactive isotopes for PET scanning count? Do we need to keep a separate log? Do we need the log completed to sit for the oral exam? Does meeting this requirement give me a license to be an authorized user? What constitutes “participation” in these six procedures? INCREASES IN RESIDENT COMPLEMENT How does the RRC evaluate requests for temporary increases in the resident complement? What documents are required in order to request a temporary increase? PERMANENT INCREASE How does the RRC evaluate requests for permanent increases in the resident complement? When requesting a permanent increase in the resident complement what will the RRC consider an adequate ‘educational justification’? What documents are required in order to request a permanent increase? LOGS Who is responsible for the accuracy of residents’ logs? How does the RRC evaluate resident logs? How should patients be counted in resident logs? How should brachytherapy procedures be counted in resident logs? REQUIREMENTS What is necessary to fulfill requirements for medical oncology, pediatric oncology, pathology, and diagnostic imaging? CURRICULUM COMPONENTS-PGY1 EXPERIENCE Is a resident permitted to use PGY-1 year experience in pathology, hematology/oncology or diagnostic imaging to fulfill the radiation oncology clinical experience requirements in these areas? PEDIATRIC NUMBERS How many pediatric patients must be treated to satisfy minimum requirements? GOALS AND OBJECTIVES The ACGME / RRC requires that the program must provide written >Goals and Objectives= for each rotation or level of training. What does this entail? SCHOLARLY ACTIVITY What is considered an Aadequate@ level of scholarly activity on the part of faculty in a training program? EXPERIENCE REQUIREMENT What is the minimum requirement for clinical radiation oncology experience and how should fulfillment of this be demonstrated? ABR EXAMINATION
  2. 2. 2 How does the RRC assess performance of a program=s residents on the ABR certifying examination? HOLMAN PATHWAY Are Holman Pathway residents included in the complement of the total number of residents approved for a program? Are Holman Pathway residents required to meet the same minimum requirements in clinical cases outlined in the program requirements? LETTERS OF AGREEMENT When are programs required to have letters of agreement for outside rotations? PROGRESS REPORTS How are AProgress Reports@ evaluated by the RRC? EVALUATIONS What is meant by a >final resident evaluation=? NOTIFICATION OF CHANGES How are Program Directors notified of changes in the Program Requirements, the Institutional Requirements? NEW UNSEALED SOURCE REQUIREMENT 1. Why do residents now have to participate in unsealed source procedures? The NRC has long recognized radiation oncologists as qualifying for “authorized user” status, based on the fact that our training includes the required exposure to and didactics in physics, radiobiology and clinical applications of unsealed sources. Recently, the NRC mandated that if radiation oncologists wish to continue to be considered for qualifying as “authorized users”, we would need to demonstrate formal “experience” with unsealed sources. In order to maintain this qualification as authorized users, it was determined that this experience would need to be formally included in the residency training requirements. 2. How many “unsealed” sources are required to be performed by the resident? After much discussion and negotiations between the ABR and the NRC, it was determined that in order to meet this requirement, residents must participate in a total of 6 cases of unsealed sources. This should be distributed as follows: 3 cases involving oral administration of >33 mCi of I-131 (i.e. Therapeutic dose not a diagnostic procedure) and 3 cases involving parenteral administration of “any beta emitter or a photon-emitting radionuclide with photon energy <150 Kev. (Note that this category includes I-131 labeled antibodies and I-131 MIBG, as well as a majority of other radioactive isotopes used for therapeutic purposes such as Samarium, or other radiolabeled antibodies administered by a parenteral route. This experience must be obtained under the supervision of an authorized user).
  3. 3. 3 3. Does administration of radioactive isotopes for PET scanning count? No. In radiation oncology, administration of diagnostic doses of radioactive sources, orally or parenterally, do not qualify for this component. We need to be participating in procedures which are therapeutic, and therefore only those procedures in which therapeutic levels of unsealed sources are used qualify. As noted above, diagnostic oral iodine scans for thyroid disease also do not meet this requirement. 4. Do we need to keep a separate log? Yes, Residents should keep a separate log of the 6 cases, signed by the authorized user. This signed log will be your permanent record. Recall that the current training qualifies you as an authorized user, but does not give you the license. The NRC will administer the license, and would require the log to confirm that your experience was performed under an authorized user. 5. Do we need the log completed to sit for the oral exam? Yes. All residents taking the oral exam in 2007 and beyond will be required to have the 6 cases of unsealed sources documented. During the transition to this requirement, it was recognized that residents graduating in 2006, may not have completed this requirement prior to completion of training. Therefore, those residents sitting for the exam in 2007 will be required to submit the log to document their six cases. Residents graduating in 2007 and beyond will be required to have this training prior to graduation, and therefore the program director’s attestation will suffice in the future. However, it is prudent for future licensure, and if any question arises, that a hard copy of the log be maintained to document completion of this requirement. 6. Does meeting this requirement give me a license to be an authorized user? No. Going through this requirement formally makes us eligible to be authorized users for therapeutic doses of unsealed sources, as we are eligible to perform interstitial and intracavitary brachytherapy. However, one still needs to get licensed from the NRC to perform these procedures, and this is accomplished in a variety of ways through your local facility, through applications submitted generally through your institution’s radiation safety office. Having gone through this process, however, the NRC will now recognize us as qualifying. Had the RRC and ABR not gone through this process of adding the practical experience in unsealed sources, we would not be able to even qualify as authorized users for unsealed sources. 7. What constitutes “participation” in these six procedures? The RRC and ABR recognize that there will be considerable variability in the resident’s degree of involvement, depending on the facility and the relationship between the authorized user and trainee. Since these procedures are generally performed outside of the radiation oncology facility, it is recognized that some residents may do formal rotations for fixed periods, where as others may do cases as they come up, without formal fixed rotations. Therefore the extent of involvement in these procedures will vary. However one fulfills the six
  4. 4. 4 case requirement, it is expected that the trainee will understand the indications for the procedure, alternatives, the radiation safety issues and the methods involved in the calculations and administration of the isotope. The trainee should be present when the isotope is delivered, and should understand the precautions and follow-up procedure. Ultimately it is the authorized user who really determines the satisfactory “participation” of the trainee and signs the form as satisfactory completed. TEMPORARY INCREASES 8. How does the RRC evaluate requests for temporary increases in the resident complement; what documents are required? Program directors may request a temporary increase in the number of residents when unforeseen circumstances result in a short-term excess in the number of residents in the program. Examples of reasons this may occur include 1) a resident delays completion of his/her residency causing an overlap with incoming residents; 2) a resident transfers from a program that has closed causing a short-term excess in the program that accepts their transfer. In general, temporary increases should not exceed one resident beyond the approved number and should not continue for more than 1 or at most 2 years. Requests are accepted or denied based on the reason for the request, the sufficiency of clinical material and faculty to accommodate a temporary increase, and on the outcome of past RRC reviews. Rarely, selected residents are permitted to alter the typical training to increase their laboratory experience (and accordingly, have decreased clinical training requirements) under the AHolman Pathway@ program. Programs with residents who have been accepted for the Holman Pathway may request a temporary increase in resident complement. 9. To apply for a temporary increase the Program Director must log on to the ADS system and provide the following: A. An educational rationale for the temporary increase request B. An explanation of how the program is addressing citations identified in the ACGME notification letter following the most recent survey review by the Residency Review Committee. C. Medical data for the most recent calendar year. Data should be submitted for all institutions and should be submitted in the format of Section 8, Program Information Forms. D. Resident logs for the most recent program graduates (4 years of experience must be included). Beginning September 1, 2007 resident logs will be submitted electronically using the ACGME Resident Case Log System. In the interim, programs are required to submit hard copies of resident logs by e-mail to nrdeyagcier@acgme.org . The Chair of the Committee may grant a temporary increase in the resident complement
  5. 5. 5 without a full RRC review. The program director should allow at least 2 weeks for a response from the RRC Executive Director. PERMANENT INCREASES 10. How does the RRC evaluate requests for permanent increases in the resident complement? Requests for a permanent increase must be reviewed by the RRC at one of its regularly scheduled meetings. Requests must be submitted through ADS. The same information that is required for consideration of a temporary increase should be submitted for a permanent increase. Requests will not be considered by the RRC if the next site visit of the program is to be scheduled within 2 years of the request date; the Committee will defer such requests until a full review of the program. 11. When requesting a permanent increase in the resident complement what will the RRC consider an adequate ‘educational justification’? • Growth in patient numbers alone will not be deemed sufficient justification for an increase in resident complement, as this will raise concerns that residents are being utilized for service. • The program must be in good standing (full or continued full accreditation) with no significant areas of noncompliance from the last RRC review. • Documentation of adequate faculty (a) as well as patient resources (b), including external beam, pediatric, and brachytherapy cases, to support the increase must be provided. • A description of improved resident-resident interactions facilitated by the increase will be considered. • Ample opportunities for clinical research as well as opportunities to utilize state-of- the-art technology would provide support to such requests. • Facilities (office space) must be adequate to support the increase in resident numbers. 12. To apply for a permanent increase, the Program Director must log on to the ADS system and provide the following: A. An explanation of the reasons a permanent increase is being requested; B. Medical data for the most recent calendar year. Data should be submitted for all institutions and should be in the format of Section 8 of the Program Information Form (PIF is accessible from the ACGME website: www.ACGME.org); C. Resident logs for the most recent program graduates (4 years of experience must be included for each of the graduating residents) Beginning September 1, 2007 resident logs will be submitted electronically using the ACGME Resident Case Log System. In the interim, programs are required to submit hard copies of resident logs by e-mail to nrdeyagcier@acgme.org; D. An explanation of how the program is addressing or has addressed citations
  6. 6. 6 identified in the ACGME notification letter following the most recent survey review by the Residency Review Committee. LOGS 13. Who is responsible for the accuracy of residents’ logs? How does the RRC evaluate resident logs? Residents are required to maintain logs (electronic logs, effective July 1, 2003) of the patients for whom they have participated in the initial simulation, or for whom they have performed other procedures (i.e, brachytherapy, stereotactic radiosurgery, etc). The program director, however, is ultimately responsible for monitoring the accuracy of these logs. He/She must review the logs with residents at least semiannually, as stated in the Program Requirements. At the time of the site visit review of the program, the RRC looks for: • Evidence that the program director is reviewing the logs with each resident twice yearly; • The number of patients simulated per year (minimum: 150/maximum: 250) and the number simulated during the course of residency (minimum: 450); • The diversity of material seen by each resident with emphasis on the number of patients with different diseases and the number of brachytherapy procedures; • Consistency between the numbers of patients counted in resident logs, the number of patients treated as documented in the PIF, and the level of coverage in integrated and affiliated facilities. 14. How should patients be counted in resident logs? A. Patients should be counted as >simulated= by a resident if: 1 The resident was present and participated throughout the initial simulation and treatment planning process; 2 The resident simulates and plans treatment of a new area on an established patient (for example a new metastasis, new primary, or new recurrence). B. Patients should not be counted as >simulated= by a resident if: 1. The case was >picked up= from another resident, even if subsequent care involves a second simulation unless this involves treatment of another area; 2. The simulation and planning were performed by staff and the resident only saw the patient after they were on treatment; 3. Another resident has counted the case on their log; 4. The patient was seen in consult only.
  7. 7. 7 15. How should brachytherapy procedures be counted in resident logs? A. Procedures should be counted as >performed= if the resident had >hands on= involvement: 1. Intracavitary procedures: The resident participated in the planning, placed the applicator in the uterus, vagina, or other cavity, participated in the selection of sources/dwell times and reviewed the dosimetry; 2. Interstitial procedures: The resident was present throughout the procedure and placed at least 1/2 the needles/sources and participated in the selection of sources/dwell times and reviewed the dosimetry; 3. Endovascular procedures: The resident reviewed the case and indications, inserted and withdrew the sources under faculty supervision, and verified the dosimetric calculations. Endovascular procedures should be counted separately and do not count as intracavitary procedures. B. Procedures should not be counted as >performed= if: 1. Another resident has counted the procedure (residents should determine up front which of them will have primary responsibility); 2. They only examined the patient, sounded the uterus, observed someone else do the procedure, reviewed the dosimetry, loaded or pulled the sources, or were otherwise involved without actually inserting the applicator/needles/sources. C. Procedures may be counted as >observed= if the resident observed or assisted in the entire procedure and reviewed the dosimetry but did not actually perform the procedure as described above. REQUIREMENTS 16. What is necessary to fulfill requirements for medical oncology, pediatric oncology, pathology, and diagnostic imaging? Residents may satisfy this requirement in one of two ways: A. Participate in rotations: 1. Medical / pediatric oncology: Residents should be involved in adult and pediatric patient care, ideally experiencing diverse indications for drug treatment for a variety of neoplastic disorders. 2. Pathology (1 month): Residents should be integrated into the service to ensure exposure to diverse material. 3. Diagnostic Imaging (1 month): Residents should be integrated into the service to ensure exposure to diverse material.
  8. 8. 8 B. Participate in multidisciplinary tumor boards: To satisfy the requirement, the Program Director must be able to demonstrate that residents are permitted and required to participate in at least weekly multidisciplinary tumor conferences attended by medical oncology and pathology. For diagnostic radiology and pathology, the multidisciplinary tumor conferences must occur monthly. Site visitors will verify attendance during the interview process. CURRICULUM COMPONENTS PGY-1 EXPERIENCE 17. Is a resident permitted to use PGY-1 year experience in pathology, hematology/oncology or diagnostic imaging to fulfill the radiation oncology clinical experience requirements in these areas? For those radiation oncology program directors who do not provide direct oversight of thePG- 1 year, and accordingly, do not control the content or curriculum components of these initial 12 months, the Committee’s response would be ‘no’. The RRC would have difficulty in evaluating the quality of residents’ experience in the areas noted above. However, for programs that are structured such that the radiation oncology program director has direct oversight or is able because of proximity to effectively be involved in the curriculum development and evaluation of these educational components, the RRC’s answer would most likely by ‘yes’. Requests will be considered on a case-by-case basis; the program director must support that the goals and objectives specific to radiation oncology have been met. PEDIATRIC NUMBERS 18. How many pediatric patients must be treated to satisfy minimum requirements? The RRC reviews diversity as well as number. In general, however, residents should simulate a minimum of 12 children (of whom at least 9 have solid tumors) during their residency to satisfy minimum standards. Programs may satisfy pediatric requirements through outside rotations. To do so, the program director must submit the following information at the time of the site visit: A. Provide a signed letter of agreement with the outside (participating) institution; B. Provide an annual summary of the total number of pediatric patients simulated at the outside institution, and an accounting of all radiation oncology residents who are assigned to rotations at this institution. Programs may supplement their residents’ pediatric experience with long-term follow-up clinics and with pediatric oncology rotations. These experiences may be valuable but cannot substitute for the basic requirement to participate in the planning and treatment of children. GOALS AND OBJECTIVES 19. The ACGME / RRC requires that the program must provide written >Goals and Objectives= for each rotation or level of training. What does this entail? Goals and objectives should be specific and should clearly articulate what the supervising
  9. 9. 9 faculty on a rotation expects a resident to master during their rotation. Very general comments such as Athe resident should achieve greater independence in treatment planning and administration@ are not sufficient. Instead, the goals and objectives should provide residents with a practical guide for their study during each rotation (the types of cases that they should treat, number of procedures, level of competency expected in specific areas, reading materials to be mastered, etc.). The goals and objectives must be provided to residents prior to their rotations and should be available at the time of ACGME site visit. SCHOLARLY ACTIVITY 20. What is considered an Aadequate@ level of scholarly activity on the part of faculty in a training program? All of the faculty must demonstrate participation in national meetings. In addition, the majority of the faculty should demonstrate active participation in effective independent research. The most commonly used benchmark for this work is publication in peer-reviewed journals. [Successful grant applications and participation in the development of clinical research trials are also considered] . A list of recent publications should indicate evidence of ongoing activity by clinical faculty and by the physicists and biologists who are involved in resident teaching and mentorship. EXPERIENCE REQUIREMENT 21. What is the minimum requirement for clinical radiation oncology experience and how should fulfillment of this be demonstrated? Residents must have a minimum of 36 months of clinical radiation oncology experience during the four years of their residency. The 36 months does not include rotations outside radiation oncology (to medical oncology, pathology etc.), nor does it include time spent outside the clinic in, for example, physics rotations. Normal vacation time does not need to be deducted from the 36 months, but unusually long periods of leave cannot be included in the 36 months. Up to a point, part-time clinical experiences that occur during a research year may be counted as clinical time but only proportional to the time spent in the clinic. Because these experiences rarely involve comprehensive management of patients on treatment, they should comprise a relatively small part of the overall experience. Evening call is not considered in this accounting. ABR EXAMINATION 22. How does the RRC assess performance of a program=s residents on the ABR certifying examination? The RRC considers all aspects of a program=s performance, including performance on the written and oral examinations, the number of failures and conditions, and any trends toward improvement. In general, however, the RRC looks at statistics regarding the proportion of first-time examinees that successfully completed the entire exam (written and oral) on the first attempt. Residents who Acondition@ a part of the examination are considered not to have passed the examination. Residents who fail the examination repeatedly are considered only once. Programs that fall in the lowest 25th percentile are cited for poor performance. In general, the programs that fall below the 25th percentile have failed to pass more than half of the residents taking the examination in a five-year period.
  10. 10. 10 HOLMAN PATHWAY 23. Are Holman Pathway residents included in the complement of the total number of residents approved for a program? Yes. Holman Pathway residents are included in the total complement of residents approved by the RRC throughout their 4-year residency training, whether in the clinical or laboratory phase of their training. The RRC will consider, on a case by case basis, temporary increases in the resident complement to accommodate programs that wish to increase their complement while the Holman resident is in the laboratory phase of their training. Under such circumstances, the program director may request this increase from the RRC through the usual procedure for gaining approval for temporary increases. It is the responsibility of the program director to outline specifically the length of time for the increase, and to outline the plan for returning to the original approved complement. This should be done at least 6 months in advance of the anticipated change in complement. Such requests should also be endorsed by the institutions office of graduate medical education. 24. Are Holman Pathway residents required to meet the same minimum requirements in clinical cases outlined in the program requirements? For special procedures, including interstitial brachytherapy, intracavitary brachytherapy, and unsealed sources, the Holman Pathway residents are expected to meet the same minimum requirements outlined in the program requirements. Holman pathway residents are also expected to meet the minimum pediatric caseload requirement outlined in the program requirements. For adult external beam cases, it is expected that Holman Pathway residents will simulate a minimum of 350 cases over their 27 months of clinical training. LETTERS OF AGREEMENT 25. When are programs required to have letters of agreement for outside rotations? A letter of agreement should be obtained for any rotation of one month or more that will occur outside the primary institution or integrated facilities. Affiliation agreements should also be developed for shorter rotations (for example, brachytherapy, pediatrics) if the cases treated during these rotations are needed for residents to meet the program requirements. Letters of agreement and formal institutional agreements must address the following: A. Identify the faulty who will assume educational and supervisory responsibility for residents and specify the faculty responsibilities for teaching, supervision, and formal evaluation of resident performance; B. Outline the educational goals and objectives to be attained by the resident during the assignment; C. Specify the period of resident assignment;
  11. 11. 11 D. Establish the policies and procedures that will govern resident education during the assignments. PROGRESS REPORTS 26. How are AProgress Reports@ evaluated by the RRC? The RRC may grant renewed accreditation to a program even though the program has been cited for noncompliance of one or more of the program requirements. Typically, the program director is asked to provide an update detailing any steps that have been taken to correct deficiencies noted in the RRC letter of report. The accreditation status of the program cannot be changed on the basis of review of a progress report [i.e., without another site visit]. However, if the committee finds that a progress report has not satisfactorily addressed the issues raised in the citations, the Committee may move up the approximate date of the next site visit. If the RRC finds that issues have been satisfactorily addressed, the letter acknowledging the progress report will indicate the Committee=s response. At the time of the next site visit and review by the Committee, all issues that were raised previously will again be examined; evidence that previous citations have not been addressed will be considered in determining future accreditation status. EVALUATIONS 27. What is meant by a >final resident evaluation=? Program directors are required to produce a final resident evaluation at the completion of each resident’s training; this is an ACGME requirement for all accredited programs. At a minimum, this evaluation must include a statement verifying that the resident has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the resident=s permanent record maintained by the institution. Program directors may want to produce more detailed final summaries to facilitate future requests for information from future employers, licensing boards, etc. NOTIFICATION OF CHANGES 28. How are Program Directors notified of changes in the Program Requirements, the Institutional Requirements? Minor changes in the Program Requirements and the Institutional Requirements may be implemented as frequently as once a year. A comprehensive review of the Requirements must occur every 5 years. Proposed changes are posted on the ACGME web site for commentary prior to approval and before they become effective. Program Directors are held accountable at the time of the program=s site visit for the document currently in effect on the ACGME web site. Program directors should periodically access this site to familiarize themselves with the Program Requirements / Institutional Requirements. H:Radiation OncologyFAQ'sNEW4FAQ (2).doc Modified 2/14/2008

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