Residency Review Committee for Radiation Oncology
FREQUENTLY ASKED QUESTIONS
PLEASE NOTE: Requests for temporary increases and permanent increases (to be considered separately from a
survey review) in the resident complement must be submitted via the ADS system. In addition, changes in
program directors, requests to add or delete a participating site, and requests to voluntarily withdraw a program’s
accreditation must also be entered via the ACGME 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?
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
What documents are required in order to request a permanent increase?
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?
What is necessary to fulfill requirements for medical oncology, pediatric oncology, pathology, and diagnostic
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?
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?
What is considered an Aadequate@ level of scholarly activity on the part of faculty in a training program?
What is the minimum requirement for clinical radiation oncology experience and how should fulfillment of this be
How does the RRC assess performance of a program=s residents on the ABR certifying examination?
Are Holman Pathway residents included in the complement of the total number of residents approved for a
Are Holman Pathway residents required to meet the same minimum requirements in clinical cases outlined in the
LETTERS OF AGREEMENT
When are programs required to have letters of agreement for outside rotations?
How are AProgress Reports@ evaluated by the RRC?
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. 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 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
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
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
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
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
The Chair of the Committee may grant a temporary increase in the resident complement without
a full RRC review. The program director should allow at least 2 weeks for a response from the
RRC Executive Director.
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
• 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
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 email@example.com;
D. An explanation of how the program is addressing or has addressed citations
identified in the ACGME notification letter following the most recent survey
review by the Residency Review Committee.
13. Who is responsible for the accuracy of residents’ logs? How does the RRC evaluate resident
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
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.
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.
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.
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
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.
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
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.
20. What is considered an Aadequate@ level of scholarly activity on the part of faculty in a training
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
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.
22. How does the RRC assess performance of a program=s residents on the ABR certifying
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.
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
C. Specify the period of resident assignment;
D. Establish the policies and procedures that will govern resident education during the
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.
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
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.
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