The case for a three year residency program in radiation oncology.

The knowledge-base requirements for radiation oncology have dramatically increased in both breadth and depth over the last decade. Advances in radiobiology, medical radiation physics, molecular biology, immunology, radiolabeled immunoglobulins, heavy particle radiation therapy, hyperthermia, stereotactic radiosurgery, conformal radiation therapy, photodynamic therapy, and interstitial implantation have greatly complicated our specialty and our relationship to other medical specialties. These advances, along with a desire to incorporate training in research techniques, have encouraged some to advocate lengthening the mandatory residency period in radiation oncology from three to four years. Two questions must be considered when contemplating such a change: (a) What is the basic fund of knowledge and experience necessary to function as a competent radiation oncologist in our contemporary medical environment? (b) How long does it take to build this fund of knowledge and experience? The training requirements for radiation oncology are currently defined by the ACGME, and there is little doubt that clinical competence in general radiation oncology, exclusive of the specialty areas listed above, can be taught in three years (1). If sufficient faculty resources and patient material are available, residents in 3-year programs should be able to acquire the radiobiology, physics, and general oncology background, along with the clinical experience needed to practice general, clinical radiation oncology in a competent manner. The performance of graduates from 3-year programs on specialty board written and oral examinations verifies this contention. Graduates from 3-year training programs have also demonstrated their ability to become involved in research efforts during their residencies. An understanding of research methodology, if not a detailed knowledge of specific laboratory techniques, is considered highly desirable by most educators in our field, and participation in clinical research is a requirement of many 3-year programs. The ASTRO resident essay award was established in 1977 to encourage and recognize outstanding research efforts by radiation oncology residents. Fifteen awards have been made, and twelve of those, (80%), have been presented to graduates of 3-year programs (2). If general radiation oncology and clinical research experience can be adequately covered during an intensive 3-year program, what would be the content of a mandatory fourth year? (Some programs may not be able to provide an adequate intensity of experience to complete resident training requirements in 3 years due to limitations of patient material, faculty, or other resources. These programs should probably be closed rather than extended for an additional year.) A year of laboratory research would be helpful to individuals who wish to pursue careers in academic medicine, and a quality experience in a quality laboratory research program might entice more of our trainees into research careers. Unfortunately, most radiation oncology residency programs in the U.S. do not have the resources to provide a year-long high-quality laboratory research experience, and a mandatory fourth year in a less than adequate lab could deter rather than encourage interest in laboratory research. The fourth year could be dedicated to clinical subspecialty study in areas such as heavy particle radiation therapy, photodynamic therapy, interstitial implantation, etc., but a mandatory fourth year in a clinical subspecialty would be limited by the treatment modalities available at each institution (many training programs would be unable to provide experience in any of these areas). Residents interested in specific subspecialty training would be delayed a year before they could begin a fellowship at an institution offering training in their area of interest. Keeping the fourth year optional would allow the provision of extra training (either clinical or laboratory) for those residents who wish to pur-