THE AGA KHAN UNIVERSITY HOSPITAL RESIDENCY MANUAL RADIATION ...

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THE AGA KHAN UNIVERSITY HOSPITAL RESIDENCY MANUAL RADIATION ...

  1. 1. THE AGA KHAN UNIVERSITY HOSPITAL RESIDENCY MANUAL RADIATION ONCOLOGY
  2. 2. CONTENTS • Preface • Introduction to postgraduate training program • Goal & Objectives • Specific Objectives • Basic Radiation Oncology Syllabus Topics to be covered • Duration and basic approach of Training • Rotations • Process of recruitments of residents • Chief resident’s role and responsibilities • Leave policy for residents • Assessment methods for residents and faculty • List of forms • Form -1 : Resident Evaluation • Form -2 : Resident Presentation Evaluation form • Form -3 : Journal Club From • From -4 : Evaluation of Resident Rotation • Form -5 : Resident’s appraisal of faculty • Recommended books • Faculty
  3. 3. PREFACE The department of Radiation Oncology is a newly commissioned facility at AKUH based at the Ibn-Zuhr building. The department has two foreign qualified consultant radiation oncologists. The cancer patients are being treated at this facility with state of the art equipments and planning systems. Following equipments are used in this service in order to deliver meticulous well planned radiotherapy to cancer patients with high level of precision and quality. Two Linear Accelerators – Varian Dual Photon ( 6 & 18 MV ) & multiple electron energies(6,9,12,15,18 MeV) Multi leaf collimation (MLC) Simulator _ Varian Acuity Eclipse Treatment Planning System 3 dimensional Conformal CT planning Brachytherapy Full mould room facilities with cerrobend pouring In addition to the above features a fully equipped High Dose Rate Brachytherapy suite and mould room are located at the basement floor of Ibn Zuhr Building. There is a Treatment Planning area where the oncologists review scans and work on treatment plans with the physics team. In addition to the clinical staff the department comprises of the following sections: Medical Physics team: One Chief Medical Physicist Two Senior Medical Physicists. Two Dosimetrists Radiation Therapy Technologists (RTT): One RTT Supervisor Radiotherapy Technologists working on Linear Accelerators,Mould Room & Simulator Nursing: Two Registered Nurses. Administration: Manager Special Projects Clerical support staff The radiation oncology department works closely with other faculty members of the University. It has a very close working relationship with the departments of Medical oncology, Radiology, Pathology and Surgery. Multi-disciplinary tumor board meetings are held on a weekly basis.
  4. 4. Consultation clinics for Radiation Oncology are held four days a week from Monday to Thursday where patients are assessed and treatment options are discussed with the patients and their families. Later on the process of booking various steps of planning commences including simulation, mould room preparation, computer planning etc. The department of Radiation Oncology will be participating in clinical trials and other research protocols developed in-house or as members of the international multi center clinical trials. The department has an Quality Improvement Committee (QIC) which is represented by each section of Radiation Oncology. All the quality procedures and parameters are monitored and documented. The QIC meets on first Saturday of every month. The head of QIC acts as the management representative for the University based Quality Improvement Co-ordination Committee (QICC). Dr Ahmed Nadeem Abbasi Dr Farrok Karsan MBBS, FFR, RCSI MD, FRCPC Director, Residency Programme Chief Radiation Oncologist
  5. 5. Introduction to the Postgraduate training program in Radiation Oncology Postgraduate training programme in Radiation Oncology is intended to be an interactive learning process. The selfactuated, thoughtful, and motivated postgraduate trainee will find AKU to be an environment which is rich in learning resources. These include the faculty, patients, libraries, computers and electronic media, as well as peers and other students. Trainees are expected to utilize all these to enhance their clinical skills and orientation. In addition to providing useful practical information, this manual also covers the system of evaluation and assessment. I would like to acknowledge the exemplary support I have received from Dr Karsan, Chief Radiation Oncologist, Dr Khursheed, Dean & Dr Syed, Associate Dean, PGME in the preparation of this manual. I would like to thank Dr Imrana Masroor, Dr Tariq and Dr Anila Kazmie for providing their valuable expert input during the entire planning process of residency programme. I would like to extend my gratitude to Professor Zaidi and all the trainers and trainees of FCPS Oncology programmes in Pakistan for sharing their experiences regarding the constituents, practical implementation and potential problems encountered during the post graduate training process of oncology residents. Lastly, I wish to acknowledge the efforts of our department secretary Anthony A. Sam in the formatting of this manual. Dr Ahmed Nadeem Abbasi
  6. 6. GOALS AND OBJECTIVES GENERAL OBJECTIVES Postgraduate training in Radiation Oncology is intended to provide the trainee with the practical clinical experience necessary to develop the knowledge and clinical skills required to manage patients with the wide spectrum of malignancies as well as the complications of these malignancies and their treatment. In general, the trainee should be able to: 1. Evaluate the appropriateness of the diagnosis and management plan prior to assessing the referred patient in radiation oncology clinic. 2. Assess the general performance status of the cancer patient. 3. Assess the patient by doing general and site specific physical examination. 4. Stage the disease and develop an overall plan of management in collaboration with other related specialists. 5. Plan and supervise the delivery of radiation treatment. 6. Follow the patient’s course during treatment and afterwards, and deal with complications of the disease and treatment. 7. Interact and communicate with the patient and family in a sensitive yet informative manner.
  7. 7. SPECIFIC OBJECTIVES A) Knowledge. B) Clinical Skills. C) Technical Skills. D) Attitude & Communication Skills E) Ethics & professionalism F) Information Technology G) Cancer Research A) KNOWLEDGE: 1. Natural history of cancer. The etiology and risk factors for development of the disease (e.g.smoking, alcohol, tobacco chewing, ultraviolet radiation, ionizing radiation, viruses, genetics,etc.) (a) The prevalence and age incidence of premalignant disease (b) The modes of presentation of malignant disease (c) Natural history of invasive disease including routes of spread or risk of regional and distant dissemination, functional effects and complications and any para-neoplastic syndromes (d) Estimation of the probability of occult local, regional and systemic spread of invasive malignancy as well as understanding the predictive value of staging tests in order to justify the appropriate staging work-up 2. Pathological classification and grading (e) Pathological classification of neoplastic disease in each tumor site and how histologic subtypes may alter management (f) The grading systems commonly used for invasive malignancy, and additional pathological steps required to achieve diagnosis (eg immunohistochemistry, electronmicroscopy, marginal status etc.) 3. Anatomy (g) Topographic anatomy of anatomic sites and sub-sites, including anatomic relationships and radiological correlations. (h) Primary and secondary echelon lymphatic drainage from specific anatomic sites and sub-sites. (i) Blood supply of vital organs. (j) Anatomical extent of cancer & with reference to imaging investigations e.g. CT, MRI etc.
  8. 8. 4. Treatment of primary and metastatic disease and second primaries: (k) Role of surgery, including selection of suitable patients, types of operations, and surgical sequelae. (l) Role of radiation therapy - indications for localized, wide field, brachytherapy and other; role of radical, pre-operative, post-operative, and palliative radiotherapy. (m) Role of chemotherapy - common agents used, interaction with radiation. (n) Symptomatic and supportive care during therapy. (o) Literature supporting treatment and level of evidence. 5. Clinical Application of Radiobiology (p) Prognostic importance of anemia and concurrent smoking (q) Optimal fractionation in different situations - radical (including dose- response relationship) and palliative (r) Hyperfractionation and accelerated fractionation (s) Brachytherapy - continuous low-dose rate - pulsed dose rate 6. Complications of treatment (t) Toxicity of radiation - mucositis, dermatitis, xerostomia, fibrosis, necrosis, myelopathy,lymphoedema,etc. (u) Side effects of chemotherapy (v) Toxicity of surgery - surgical extirpation and surgical reconstruction. B) Clinical Skills 1. History and physical examination (a) Problem based history and physical examination to localize lesions (b) Establish a differential diagnosis of the pathological process (c) Request appropriate investigations (d) Assessment and management symptoms of pain, dysphasia and dyspnea caused by the tumor
  9. 9. (e) Assessment of quality of life and performance. C) Technical Skills The trainee should be able to plan a radical or palliative course of treatment with detailed knowledge of each stage of the technique 1. Immobilization - mould technique – thermoplastic breast board, etc 2. Conventional simulation (a) Using clinical examination, CT and MRI (as appropriate), surgical reports, and knowledge of pathology - define extent of disease (b) Gross tumor volume (c) Clinical target volume (d) Planning target volume - justify margin left around tumor (e) Critical normal structures (f) Shielding (g) Appropriate technique - single field, multiple field, single isocentre vs more than one isocentre. 3. Two & 3 Dimensional Conformal Planning (a) Ability to define Gross Tumor Volume (GTV), Clinical Target Value (CTV) and Planning Target Volume (PTV) using clinical, diagnostic CT scan/MRI information and surgical report. (b) Critical normal structures - definition (c) Beam’s-eye view approach to field design 4. Dosimetry (a) Optimization of isodose plan. (b) Selection of appropriate isodose for prescription. (c) Matching fields and calculation of gap (if appropriate) between fields. (d) Use of bolus. (e) Compensation for changing tissue contour - wedges vs retracted compensators
  10. 10. (f) Skin sparing. (g) Evaluation of dose-volume histograms (DVH) for target volume in normal structures. 5. Dose prescription (a) Dose/fractionation/overall time (b) Photon vs electron and beam energy selection; machine selection (c) Interpretation of portal images - comparison with digitally reconstructed radiographs, conventional simulation films, custom and multi-leaf collimation 6. Brachytherapy (a) Assessment of patient and tumor regarding suitability for temporary implant, permanent implant, mould. (b) Integration of brachytherapy in external beam management. D) Attitude & Communication skills (a) Listening to patients and answering patients questions clearly and understandably (b) Showing empathy for their concern and emotional state (c) Providing appropriate and understandable information on the disease, any tests required, the likely clinical course, the therapeutic options available including benefits and side-effects to the patient and family (d) Explaining the results of tests, treatments and prognosis honestly, balancing the responsibility for providing a realistic appraisal of the clinical condition with the need to preserve hope, and involving the patient in treatment decision making (e) Appraising the pyscho-social impact of diagnosis and treatment on the patient and relatives including housing, transportation, work and loss of income, care giving and stress E) Ethics and Professionalism Objectives 1. Describe laws and codes governing the practice of medicine. 2. Apply ethical principles in patient care and research. Content Ethical principles and application in clinical practice. Physicianship: integrity, compassion, respect, availability, life-long professional competence, continuing education.
  11. 11. Ethics: consent, patient requests, decisional capacity, patient impairment, surrogate decision maker, dying and death, privacy, withdrawal of treatment, substance abuse in colleagues, autonomy, beneficence, non-malficence, justice, physician-patient and physician-colleague relationships, research ethics. The principal areas of competence for Radiation Oncology Trainees • Clinical expertise and judgment; • Ability to establish effective relationships with patients; • Leadership and personal management skills; • Organisation, planning and service management skills; • Education and mentoring abilities; Quality standards, effectiveness, research and development skills. F) INFORMATION TECHNOLOGY SKILLS Objectives 1. Apply computer technology in medical literature search, and medical record keeping and retrieval. 2. Use computer technology to store and process research data. Content File organisation, floppy and hard disk storage and protection of information, word processing, spreadsheet, database and computer-based presentations. Internet access and use. Statistical programmes (Epi. Info, SPSS), statistical tests, data entry, data cleaning, variables and coding. G) CANCER RESEARCH SKILLS Objectives 1. To apply research methods in designing cancer research proposals. 2. Explain the purpose of cancer research. 3. Describe different types of research. 4. To select appropriate study designs. 5. Design research instruments. 6. Disseminate research findings. Content Research definition, nature of use and application, scientific enquiry, concept nature and process. Types of cancer research designs: descriptive, cross-sectional, analytical, longitudinal, cohort, retrospective, case control, experimental, clinical trials, community/field trials, quasi-experimental.
  12. 12. Research methods: qualitative, quantitative. Sampling methods and sample size determination. The role of Institutional Research and Ethics Committee. Research instruments: questionnaires, interview guides, their characteristics and application. Report writing: study title, abstract, introduction, study objectives, methods and materials, results, discussion, conclusion, recommendations, appendix, bibliography, acknowledgements. Dissemination of research findings, methods of dissemination, scientific papers, reports, seminars, use of findings.
  13. 13. Duration and basic approach of Training The postgraduate teaching programme of the Department of Radiation Oncology includes a four-year fully structured training programme, offering clinical training in Radiation Oncology adherent to the requirements of the College of Physicians and Surgeons Pakistan. Specific rotation structure is being devised in order to coach the trainees in the most comprehensive system of multidisciplinary team working environment. The Resident will learn to function in harmony with other members of the health care team and become proficient in interpersonal relationships and in the organization and management of patient care. Provision of the opportunity to function within the context of a multi-disciplinary team approach to cancer patients care through interacting effectively with specialists of other disciplines, nurses, unit receptionists, nutritionists, pharmacists, physiotherapists, social services and other paramedical personnel. Over a training period of five years, the Residency Programme provides extensive experience and training to residents who acquire the knowledge, skills and attitudes required to practice medicine as an specialist.
  14. 14. Specific Rotations Objectives: It is internationally recognized that care and management of cancer patients can be effectively delivered via multidisciplinary approach. An oncologist interacts with almost all the disciplines of medicine on a regular basis. He or she plays an important role in the organization and activities of a multidisciplinary team. The main objective of extra-oncological rotations is to give a comprehensive and versatile vision of cancer care to the Trainee Radiation Oncologist. The rotations will be started in the 3rd year of training. In the fourth year all the CPSP rotations are covered. The trainees will rotate to departments which interact very closely with the Radiation Oncologist. It is intended that they would develop a sense of team work and would have a clearer understanding of view points and opinions of other specialist colleagues. a) Rotations during 3rd year of Training Surgical Oncology 1 month Pediatric Medical Oncology 1 month E.N.T 2 weeks b) Rotation during fourth year of training (as per CPSP requirements) Internal Medicine 3 months Medical Oncology 3 months Pathology 2 months Diagnostic Radiology 6 weeks Nuclear Medicine 6 weeks Anesthesia 2 weeks Psychiatry 2 weeks
  15. 15. c) Elective Rotations: As per clinical training requirement the option of elective training rotations would be discussed with the trainee and the same would be arranged in appropriate departments.
  16. 16. Basic Radiation Oncology Syllabus Topics to be covered Medical Physics: 1. BASIC PHYSICS Definitions and concepts: Matter, Force, Energy (concept and energy levels), Electrical Charge, Interaction of Charges, (Electrical & Magnetic Fields) Structure Matter: of Atom and its constituents, Atomic and Mass numbers. Atomic units. Mass Defect and Binding Energy. Electron ‘shells’ and energy levels. Radioactivity: Nuclear forces, stability and energy levels. Radioactive decay and its types. Activity and its units. Half life and mean half life. Radioactive equilibrium. Parent and daughter elements. Radioactive series. Natural and artificial radioactivity. Fission, fusion and Nuclear Reactors. Electromagnetic Radiation: Wave and quantum model. Electromagnetic spectrum. Relationships between wavelength, frequency energy. Ionizing and non-ionizing Radiation and their types. Structure of Solids: Band theory for insulators, conductors and superconductors. Impurity levels (donor and acceptor). 2. X-RAYS AND THEIR PROPERTIES: Production: Brief history. Basic x-ray Tube. Bremsstrahlung and characteristic x- rays. X-ray Energy Spectra. Interaction with Matter: Ionization and Excitation. Photon Beam Attenuation and Absorption. Coefficients of Attenuation, Energy Transfer and Absorption, their differences and Variation with Beam Energy. Specifications and Measurement of Beam Quality. Filtration. Interaction Processes: Coherent Scattering, Photoelectric, Compton, Pair Production and Photo-nuclear interactions. Dependence on Atomic number and Relative importance in diagnosis and therapy.
  17. 17. 3. PARTICLE BEAMS AND THEIR INTERACTIONS: Interactions of Light and Heavy Charged Particles: Ionization Effects: Ionization versus Energy. Stopping Power and L.E.T. Bragg Curve. Definition of particle range. Interactions of Neutrons. Comparative Beam Characteristics. 4. TREATMENT UNITS IN RADIOTHERAPY: Kilovoltage Units: Different types, their Construction and Energy Range. Filtration. Factors effecting output. Megavoltage Units: Principles of Operation, Details of Construction, including treatment head and principles of cooling. Co-60 units - to include also source construction, methods of safety control. Linear Accelerator – to include also microwave production, beam control and stability. Van De Graff Generator, Betatron, Microtron, Cyclotron. (overview only). Beam Collimation: Applicators (x-ray and electron), Collimators, Multi-leaf Collimators (MLC), Effects on Penumbral size, Additional shielding arrangements, materials and doses under shields. Equipment operational and safety controls: For orthovoltage, Cobalt and linear accelerators. Interlocks. Select/Confirm systems and verifications/recording. Use of Equipment: Commissioning measurements and Quality Control checks. Merits of equipment, specific hazards. Limitations of equipment use. Methods of verification. 5. MEASUREMENT AND DETECTION OF IONIZING OF RADIATION: Radiation Exposure: Definition, Units and Measurement. Measurement of Exposure: Ionizing Chambers, Mechanism of measurement, types, calibration methods (intercomparisons, standards, corrections, determinations in physical practice and desirable characteristics. Radiation Dose and Kerma: Definition, Units and Measurements. Inter-relationships between units. Variation with energy, material. Measurement of Absorbed Dose: Calorimetry, Chemical Dosimetry Film Dosimetry, Scintillation Dosimetry and Thermo luminescence Dosimetry. Calibration Protocols, Materials (phantoms) for dose measurements, Detectors for dose measurements. Assessment of Accuracy.
  18. 18. 6. DOSE DISTRIBUTION AND SCATTER ANALYSIS OF X-RAY BEAM: Percentage Depth Dose: Dependence on Depth and Radiation Quality, Field Size and Shape, Source-Surface Distance. Tissue-Air Ratio: Effect of Distance, Energy, Depth and Field size. Definitions of: Percentage Depth Dose, Tissue-Air Ratio, Back-scatter Factor, Peak- Scatter Factor, Scatter Air-Ratio, Tissue-Maximum Ratios. Use of the above factors and Ratios. Equivalent Square Charts. Beam Geometry: Magnification and Penumbra. Field Size Definition. 7. PRINCIPLES OF TREATMENT PLANNING & DOSE CALCULATION: Treatment Dose Calculations: Dose calculation parameters and their significance. Use of Output, Depth Dose and Eq-Square Charts. Fixed SSD and Isocentric calculation techniques and their practical applications. Rotation calculation using TAR. Planning Computers: Use of computers for dose planning (overview). Description of Component parts. Description of simple algorithms. Isodose Distributions: General properties of X- and gamma ray isodose charts. Parameters effecting isodose distributions. Isodose modifying devices: Use and measurement of wedges. Wedge angle definitions. Compensators. Interface effects. Description of: Fixed SSD, Isocentric set-ups. Field size and Field Weight Definitions. Combination of Radiation Fields: Parallel opposed fields. Multiple field arrangements. Beam balancing by wedging and weighting. Overview of treatment planning arrangements. Isocentric stationary and rotation therapy. Tumor dose specification for external photon beams: Terminology used- tumor, treatment and Irradiated volumes. Localization of target volume and specification of dose. Patient data acquisition: Use of manual body contours. Use of Simulators. Use of Ultrasound CT and MRI systems. 3D treatment planning. Treatment Verification systems: Use of port films. Electronic portal imaging. Check and verify systems. Patient Alignment and Immobilization: Methods beam alignment (isocentre marks, laser marks, front/back pointers). Methods of immobilization (bite block, face masks, neck rolls/head rests, alpha cradles/Vac locks, breast boards etc.)
  19. 19. Field shaping and Shielding devices: Lead (Cerrobend) blocks. Custom blocking. Photon and electron shielding. Independent jaws. Multileaf collimators(MLC). 8. ELECTRON BEAMS: Production: Electron Beams from medical accelerators, beam collimation methods and hazards. Electron interactions and scattering: Specifications of beam energy and measurement. Output calibration and determination of depth doses. Clinical Electron Beam Characteristics: Depth-dose versus energy, field size, Isodose shapes field flatness and symmetry, electron source and x-ray contamination. Treatment Planning: Selection of energy and field size. Production of irregular shaped fields. Surface obliquity and tissue inhomogeneities. Use of bolus. Setting up adjacent fields. Internal and external shielding. 9. BRACHYTHERAPY: Introduction: Definitions. Historical Perspective. Comparative Advantages and Disadvantages over Teletherapy. Types/Categorization of Brachytherapy: By Location- (Intracavitary, Interstitial, Molds or Plaques). By Type of Loading-(Manual Loading, Manual After Loading, Remote After Loading). By Dose Rate- (Low-Dose-Rate, Medium-Dose-Rate, High- Dose-Rate). By duration- (Permanent and Temporary Implants). By Types of Radiation Emitters- (Gamma, Beta and Neutron). Basic Physics of Brachytherapy: Isotopes used in clinical radiation medicines- (Radium-226, Cesium-137, Irridium-192, Gold-198, Iodine-125, Calfornium-252, Palladium-103 and Strontium-90). Physical Characteristics and Properties of isotopes used. Source Strength specification (Content and Apparent Activity, Exposure Rate, Equivalent mass of Radium). Specific hazards. Use of Unsealed Isotopes-Requirements of Radionuclides for therapy and diagnosis. Dosimetry. Production of unsealed isotopes. Radiation Protection requirements. Principles of Clinical use: Overview of use of different forms (e.g. seeds, tubes, needles, wires). Distribution rules and dose calculation basis for Manchester and Paris systems. Clinical examples. Control and Testing of Sealed Sources: Measurement of activity. Storage and movement control. Source handling and transportation. Leak testing, inspection. Safety devices/precautions (sealed source room, theatre and wards). Principles of After loading: Types of after loading (manual, LDR, HDR), source details. Benefits, Specific requirements. Hazards.
  20. 20. 10. RADIATION PROTECTION: Regulatory framework: Dose equivalent. Effective dose equivalent and risk estimates. Background radiation. Low level exposure effects. Current Effective dose equivalent limits for public and staff. Classification of staff, designated areas. International and National Regulatory Authorities and their guidelines and rules. Protection mechanisms: Time, Distance, Shielding. ALARA principal. Structural shielding design. Primary/Secondary barriers. Leakage and scattered radiations. Neutrons shielding. Design of Sealed Sources storage and dispensary facilities. Radiation protection surveys: Survey and monitoring instrumentation. Contamination instrumentation. Calibration requirements. Equipment and area survey. Personnel monitoring: Dose reporting mechanisms and dose levels allowed and received. Construction and operating principles of: film badge, TLD badge, Direct Reading Dosemeter. National regulations: Licensing of equipment and facility. Other related issues. Administrative and technical requirements. Regulations governing use of teletherapy units containing sealed sources (Cobalt-60 and Cs-137). Training and experience requirements. Radiobiology: 1. The Physics and Chemistry of Radiation Absorption 2. DNA Strand Breaks and Chromosomal Aberration 3. Cell Survival Curves 4. Dose-Response Relationships for Normal Tissues 5. Model Tumor Systems 6. Radiosensitivity and Cell Age in the Mitotic Cycle 7. Repair of Radiation Damage and the Dose-Rate Effect 8. The Oxygen Effect and Reoxygenation 9. Linear Energy Transfer and Relative Biological Effectiveness 10. Radiosensitisers and Bioreductive Drugs 11. Radioprotectors 12. Cell, Tissue and Tumor Kinetics 13. Time, Dose and Fractionation in Radiotherapy 14. New Radiation modalities 15. Predictive assays 16. Hyperthermia 17. Chemotherapeutic Agents from the Perspective of the Radiation Biologist 18. Acute Effects of Total-Body Irradiation 19. Radiation Carcinogenesis 20. Hereditary Effects of Radiation 21. Effects of Radiation on the Embryo and Fetus 22. Radiation Cataract genesis 23. Molecular Techniques in Radiobiology 24. Radiation Protection
  21. 21. MEDICAL STATISTICS: 1. Clinical trials: problems of retrospective comparisons and use of historical controls, prospective randomized controlled studies, protocols patient eligibility, informed consent, methods of allocation treatment options, numbers required, multi-centre studies, double-blind studies, interim and sequential analysis, crossover trials. Biological variation, tumor regression, quality of life, morbidity, local and regional recurrence, distant metastases, death. 2. Data recording and presentation: qualitative data, data recording graphs and charts, histograms, proportions, contingency tables, quantitative data, summarizing statistics including mean, variance, range, standard error, the Normal distribution. 3. Sampling: concept of source population, random sampling, estimating of population statistics, standard error of sample mean and of a proportion and their differences. 4. Survival and recurrence data: concept of cure and recurrence free rates, crude age and actuarial survival rates, age-adjusted survival rate, life-table (actuarial) calculation of survival rate, survival curves, comparison of two curves, log rank test, Cox (proportional hazards) model. 5. Statistical inference: confidence intervals, significance tests, null hypothesis, type I and II errors, analysis of variance and contingency tables, simple linear regression, correlation, non-parametric analogues of the t-test and correlation. 6. Epidemiology: Morbidity and mortality rates, standardized mortality rates, cancer registration and follow-up, life tables, cancer detection and statistical approach to etiology, cancer incidence, trends in cancer incidence, trends in cancer incidence and mortality, etiological and diagnostic studies.
  22. 22. Residency Program Committee A) Terms of Reference • This committee shall be responsible for the development, implementation, and review of the postgraduate curriculum. • The committee will be chaired by the head of Residency Programme • The committee shall also be responsible for the general administration of the program, which includes: o Recruitment and selection of residents o Teaching, o Rotation of residents o Supervision o Counseling o Evaluation and o Advancement of residents • The committee shall also be responsible for maintaining resident’s personnel records.
  23. 23. B) Committee Members The Residency program committee will comprise of the following representatives: 1) Head of Radiation Oncology Programme. 2) Chief of Radiation Oncology Department 3) Representative from Medical Oncology. 4) Representative from Diagnostic Radiology. 5) Representative from Internal Medicine. 6) Chief Resident
  24. 24. PROCESS OF RECRUITMENT OF RESIDENTS Department of Radiation Oncology recruits all it’s staff on the basis of open competition and merit .The first step of hiring a resident is an open advertisement in the print media. Residents are recruited in accordance with the policies prepared by the Interns and Residents Committee. All the existing AKUH Human Resources policies would be followed throughout the recruitment process. The applicant must hold an MBBS degree and a 12 months house job/internship certificate. He or she should have already cleared the FCPS-Part I in Radiology. Applicants are then subjected to appear in an MCQ exam, conducted by PGME (postgraduate medical education) department. This exam will be conducted on an annual basis. The successful candidates will then be shortlisted and called for an interview. Two separate examiners, who also score separately, interview the candidates. Selected candidates are asked to attend a three-day orientation programme arranged by PGME. GRADED RESPONSIBILITY OF RESIDENTS: Trainee should be able to perform the following under supervision: Responsibilities during year 1-3 (a) Apply basic knowledge to perform an appropriate history and physical examination (b) Present the case summarizing the important facts and finding, recommend staging tests, discuss general principles of treatment including the role of radiation with approximate treatment results (c) Plan simple, radical and palliative treatment (d) Plan and defend a staging work-up (if appropriate) and evaluate results of investigations
  25. 25. Responsibilities during year 4& 5 a) Propose and defend a management plan that may include surgery, radiation, and chemotherapy. (b) Communicate this plan to patient, family and other members of the health care team, answering questions regarding treatment outcome and toxicity (c) Plan more complex radical and palliative treatments, including multifield techniques and implants (where appropriate) (d) Discuss the controversies in the management and cite key literature in the area
  26. 26. CHIEF RESIDENT’S ROLE & RESPONSIBILIIES 1. Member of resident training committee, appointed upon recommendation of residency Training Committee to Department Chair. 2.Prepares the minutes of resident training committee meetings. 3. Under direction of Program Director/Co-ordinator, organizes on-call duty rota, annual duty rotation and earned leaves. 4. Under direction of Program Director/Co-ordinator, deputizes resident’s extra duty, participates in disciplinary action proceedings and organizes clinical meetings. 4. Monitors as liaison attendance of department academic rounds. 5. Acts between faculty and resident body. 6. Reports to Program Director and Resident Training Committee. 7. Organizes and Chairs general meeting of resident body (at least 6 meetings annually). Serves for 1 year
  27. 27. LEAVE POLICY FOR RESIDENTS 1. Maximum number of residents on leave at one time will not be more than three 2. Applications for leave in the coming month should be submitted till 15th of the ongoing month. 3. Leave planner for residents. Leave planner to be displayed in secretary’s office and on the notice board. 4. Documentation of all leaves (sick, casual and earned leaves). When a resident goes on leave he/she signs a leave register maintained by the secretary at the time of going on leave and resuming duty. 5. Disciplinary action for all uninformed, unplanned and unapproved leaves, e.g. an extra night call. 6. There is no casual leave for the resident. 7. All leaves to be informed to (co-ordinator/chief resident/physician in charge and secretary in that order) before 10 a.m. otherwise it would be treated as unpaid leave 8. Maximum duration of leaves for residents is two calendar weeks at one time.
  28. 28. ASSESSMENT METHODS FOR RESIDENTS & FACULTY 1. In training skills appraisal report. * Two monthly on rotation basis. * Report is completed by rotation preceptor. * Discussed with resident and signed. * Comments added by Co-coordinator. * Accumulated reports reviewed at the end of year. 2. Written examination. * 3-monthly MCQ/TOACS (Task oriented assessment of clinical skills) * Periodical Physics Tests (MCQ/Essay Type) * Accumulated results reviewed at the end of year. 3. Viva Voce examinations.- * Every 6 months Accumulated results reviewed at the end of year. 4. Performance at Departmental Presentations and Journal Clubs (Forms enclosed) * Attendance * Quality of presentation * Style * Content * Performance review will be discussed with resident at the end of year.
  29. 29. LIST OF FORMS Form -1 Resident Evaluation Form -2 Resident Presentation Evaluation form Form -3 Journal Club From From -4 Evaluation of Resident Rotation Form -5 Resident’s appraisal of faculty
  30. 30. RADIATION ONCOLOGY RESIDENT EVALUATION Name: ____________________________________ Date: ___________________ Residency Level: ___________________________ Inclusive Date: ___________ Evaluating Faculty: CRITERIA 1 2 3 4 CLINICAL SKILLS: Theoretical Knowledge Application of Theory Technical Skills Clinical Correlation Problem solving WORK HABITS: Punctuality Completion of assignments Willingness to learn Attitude towards hard work Contribution to department Interest in research activities PERSONAL QUALITIES Administrative and leadership qualities Maturity and independent thinking Performance under stress Ability to undertake responsibility Verbal communication skills Relationship with Medical Staff Relation with other staff Demonstrate personal honesty & caring attitude Maintain proper decorum & demeanor FORM - 1
  31. 31. COMMENTS: General Professional Plan & Goals FINAL RATING: 4 3 2 1 RECOMMENDATIONS: SIGNATURE PROGRAM DIRECTOR SIGNATURE RESIDENT Discussed with resident and copy handed over. 4. Excellent: Exceptional, superior, far exceeds reasonable expectations, only a few Resident can earn this. 3. Good: Unusually strong, often exceeds reasonable expectations but it is really not Outstanding. 2. Average: Equals to the majority of residents at this level of training, occasionally Exceeds reasonable expectations (most rank here) 1. Poor: Not acceptable for a resident at this level of training. Recommendations for remedial work. NOTE: This completed form must be referred to the Residency Coordinator for His/her written comments and any further discussion with the concerned Resident.
  32. 32. DEPARTMENT OF RADIATION ONCOLOGY Resident’s presentation assessment Date : _____________ Presenter: _________________________________ Level of Residency ______ Evaluator : ________________________________________________________ Topic : ___________________________________________________________ Serial No Criteria. 1 2 3 4 A. Contents 1. Introduces & summarizes topic in an interesting way. 2. Covers the topic adequately and appropriately. 3. Presents well researched and referenced content. B Methodology 4. Get the point of view across the audience. 5. Involve the audience. 6 Keep up to time limits. C. Communication 7. Uses audible language fluently and coherently. 8. Uses Appropriate gestures, body language and eye contact. 9. Confidently handles questions. D.Visual Aids 10. Uses Clear Visual aids relevant to spoken words. 11. Spelling Mistakes (No spelling Mistakes is 4) 12. Describe the Images rightly and confidently. Comments: _______________________________________________________ Evaluator’s Signature -------------------- Presenter’s Signature. ------------------- Evaluation counting: Total Marks-48. 1.Poor. (Total Score=1-12) 2.Unsatisfactory. (Total Score=13-24) 3.Satisfactory. (Total Score=25-36) 4.Outstanding. (Total Score=37-48) FORM - 2
  33. 33. DEPARTMENT OF RADIATION ONCOLOGY Journal Club – Resident’s Assessment Form Presenter: Evaluator: Date: Level of Residency: Points on which scoring will be made. 1 2 3 4 1 Selection of article. 2. Understanding of topic and statistics. 3. Get the point of view across the audience. 4. Use of tables and charts 5. Time management 6. Language fluency and coherence 7. Use appropriate gestures and body language 8. Use clear visual aids relevant to the spoken words. 9. Searched other articles other than the selected article on same topic. 10. Ability to defend or critique the selected article. 11. Confidently handle the questions. 12. Practical Application of article. Comments: Evaluator’s Signature: Presenter’s Signature : Evaluation counting: Total Marks-48. 1-12.Poor. 13-24 Unsatisfactory. 25-36.Satisfactory. 37-48.Outstanding. FORM - 3
  34. 34. DEPARTMENT OF RADIATION ONCOLOGY EVALUATION OF RESIDENT ROTATION ( extra-departmental) Rotation Type: ______________ Preceptor: ______________________________ Were all objectives of Rotation met? a) Adequate Supervision. b) Sufficient experience – reporting/technical procedures. c) Teaching d) Responsibility e) Relationship - Technical staff/Radiographers - Secretarial Staff - Referring clinicians/nursing staff - Others f) Other Comments (e.g. quality of equipment) FORM 4
  35. 35. FORM 5 THE AGA KHAN UNIVERSITY DEPARTMENT OF RADIATION ONCOLOGY Resident’s Appraisal of Faculty Name of Faculty _____________________________________ Period of Evaluation _____________________________________ Level of Residency (Mandatory) _____________________________________ Contact with faculty in hrs: _____________________________________ Please rate the following categories by checking the appropriate box. Comments: Demonstrate ability to communicate ideas effectively Poor Fair Very Good Excellent Is able to answer questions clearly Poor Fair Very Good Excellent Is able to challenge Resident’s thinking Poor Fair Very Good Excellent Successfully uses teaching films and aids (such as videos, charts, demonstrations etc) Poor Fair Very Good Excellent Is able to provide useful feedback Poor Fair Very Good Excellent Demonstrates positive attitude towards teaching Poor Fair Very Good Excellent Observes and objectively comments on Resident’s professional skills Poor Fair Very Good Excellent Provides a good professional role model Poor Fair Very Good Excellent Overall effectiveness as teacher Poor Fair Very Good Excellent
  36. 36. Comments: ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ EXCELLENT: Faculty member consistently provides lectures, tutorials or clinical sessions Regarded as enjoyable, helpful learning experiences. The student looks forward to his/her teaching sessions. Only a small fraction of the faculty would fall in this category. GOOD: Faculty member provides well organized learning opportunities from which the student benefits most of the time. Most faculty will fall in this category. POOR: Faculty member consistently provides confusing or unhelpful teaching sessions from which the student learns very little. The student is tempted to skip his/her sessions. Only a small fraction of the faculty may be expected in this category.
  37. 37. RECOMMENDED BOOKS FOR INTERMEDIATE MODULE AND FINAL EXAMINATION OF FCPS IN RADIATION ONCOLOGY • Cancer: Principles and Practice of Oncology – de Vita, Hellman & Rosenberg (Lippincott Williams & Wilkins) • Oxford Textbook of Oncology – Souhami, Tannock, Hohenberger & Horiot • Practical Radiotherapy Planning – Dobbs, Barrett & Ash (Arnold) • The Physics Of Radiation Therapy – Khan (Lippincott Williams & Wilkins) • Radiotherapy Physics in Practice – Williams & Thwaites (Oxford University Press • Radiobiology for the radiologist – Hall Giaccia (Lippincott Williams & Wilkins) • Practical Chemotherapy: A Multidisciplinary Guide (Radcliffe Medical Press) • Radiotherapy in Practice: Brachytherapy – Hoskin & Coyle (Oxford University Press) • International Commission on Radiation Units (ICRU) Report 50: Prescribing, Recording and Reporting Photo Beam Therapy • ICRU Report 62: Prescribing, Recording and Reporting Electron Beam Therapy (Supplement to ICRU Report 50) • ICRU Report 62: Prescribing, Recording and Reporting Electron Beam Therapy • Introduction to the cellular and molecular Biology of Cancer-Knowles & Selby (Oxford University Press) • Basic Clinical Radiobiology – Steel (Arniod) • The Basic Science of Oncology - Tannock, Hill, Bristow & Harrington (McGraw-Hill) • The Genetic Basic of Human Cancer – Vogelstein & Kinzler (Oxford University Press) • Cancer Chemotherapy & Biotherapy: Practice – Chabner & Longo (Lippincott Williams & Wilkins) • Cancer Clinical Pharmacology – Schellens, McLeod & Newell (Oxford University Press) • Oxford Textbook of Palliative Medicine – Doyle, Hanks, Cherny & Calman [Sections 7 & 9] 3rd Ed 2003 (Oxford University Press) • Epidemiology fir the Uninitiated – Coggon, Barker & Rose (BMJ Books) • Clinical Trails in Cancer: Principle and Practice – Girling, Parmar, Stenning, Stephens & Stewart (Oxford University press) • An Introduction to medical Statistics – Bland (Oxford University Press) • Medical Statistics at a Glance – Petrie & Sabin (Blackwell Science UK) • Clinical Epidemiology: A Basic Science for clinical Medical – Sackett, Haynes, Tugwell & Guyatt (Lippincott Williams & Wilkins) • Medical Statistics: A Commonsense Approach – Campbell & Machin (John Wiley & Sons)
  38. 38. • Practical Statistics for Medical Research – Altman (Chapman & Hall) • Geometric Uncertainties in Radiotherapy 2003 (The British Institute of Radiology) • A Primer on Theory and Operation of Linear Accelerators in Radiation therapy - Karzmark & Morton (Atlantic Books)
  39. 39. FACULTY Dr Farrok Karsan, MD (USA),FRCPC (Canada), Asst Prof. & Chief Radiation Oncologist Dr Nadeem Abbasi , MBBS (Dow)FFR (Radiotherapy & Oncology), RCSI (Dublin). Asst Prof. & Radiation Oncologist Dr Nasir Ali,MBBS (Punjab), FCPS (Pakistan). Senior Instructor, Radiation Oncologist

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