Moral Dilemma...

[radoncmonkey]

I am a resident at very clinically-slanted program...no so academic. There is a dearth of research and teaching is also pretty, uh, laid back. We recently had an RRC site visit which resulted in several "warnings."

One warning was in reference to didactics. Our didactic sessions consist of a one hour presentation weekly which is entirely resident led. That's it. I mean, we get radbio and physics on top of that..but in terms of clinical didactics we really don't get ANY formal didactic lectures from attendings.

So it turns out the RRC stipulates that there is an 80/20 rule. 80% of lectures are supposed to be given by attendings. So here comes the moral dilemma part:

Our PD has requested that when residents present, on paper we should make it look like the attending presented. So yeah, she's asking us to, uh, bend the truth?

The problem is, from her perspective, it will be impossible to change our program overnight and by the next RRC visit if things don't change, they could take serious action. So the best interest of the residents is to make everything look nice and tidy on paper. However, I don't feel good about that. But I also don't like the alternative with the corresponding consequences..

Any thoughts?

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[nod]

sorry to hear about your situation. matching into rad onc is hard enough, you hope your program will be around through your training.

i am surprised to hear the 80/20 rule. i have seen two programs in some detail (med school and residency), and neither had attendings give 80% of the talks (the attendings lecture, but not anywhere near 80%). i wonder what the specifics of that rule are in terms of what counts as an "attending lecture." most of the talks are given by residents, but there is usually always attendings present at these talks, and there is also a specific attending assigned to the talk and the attending is technically supposed to help us put it together if we need help (we rarely ever do).

others can comment on their own programs, but i doubt there is a program out there where attendings are doing the majority of the lecturing in the morning. as they say, giving talks on a topic is how we learn.

 

[deleted4401]

I agree that it is an uncomfortable situation.

To work around it, I would say that if my program shut down and I didn't get to complete training, then there would be many patients who would not get treated by me. And that would be a shame, if you've seen me in action

Sometimes these things come up with residency training and site visits; there are situations that are definitely not areas of moral clarity. But it is so hard to get a training spot and if your program is in jeopardy or tainted in any way, then you are tainted, as well. Unless the program is abusing you in some way or mistreating patients, I think it is best to just go with the flow and sign in for the attending. Discuss it internally, and maybe it will be an opportunity for you to get the attendings more actively involved.

We definitely don't get 80/20 - I had no idea that was the rule.

S

 

[qwert]

If the program is not probation, chances are you'll be alright even if ACGME finds out.
However, if the attendings don't care about giving a lecture, this will unlikely change no matter what you do.

 

[IndyXRT]

Hmm - I just skimmed through the ACGME program requirements for radiation oncology (available here: http://acgme.org/acWebsite/RRC_430/430_prIndex.asp). Under II. B. 5. it states "The faculty must establish and maintain an envirement of inquiry and scholarship with an active research component. a) The faculty must regularly participate in organized clinical discussions, rounds, journal clubs, and conferences."

I couldn't find any mention of an 80:20 rule anywhere. I know that at my institution, the proportion doesn't fall out this way. We do often have faculty present at didactic (which we do twice per week). We have faculty presentations from both our own faculty and outside faculty (surgeons, medical oncologists, radiologists, pathologists, etc). Perhaps this would be a way you could boost faculty presentation numbers (most faculty are happy to give a presentation or two when invited). I think it is a good goal to have more faculty presentations. However, I would try to clarify the 80:20 thing, because I can't find where it comes from (and if you do find out where it comes from, please post it or PM me).

 

[Adawaal]

You've been grossly misinformed about the "80/20 rule." It just doesn't exist (at least not as a general Rad Onc RRC/ACGME requirement, although I suppose the RRC may place additional requirements upon programs on probation).

I have never been able to figure out why it is, but Rad Onc seems to find itself in a relatively unique situation in regards to didactic education. If you examine the didactic schedules of many other specialties' training programs, you'll find a much richer experience than we have. Might it be a regressive attitude arising from the relatively unique 1-on-1 apprenticeship model we utilize that for the most part medicine has left behind? I honestly don't know.

However, specifically addressing the "80/20 rule," even if it existed, it would be a very bad thing, IMHO. Think about topics you know the most about. Did you learn that info from listening to a staff member talking for 60-90 minutes about it? It's most likely the topics that you yourself had to research and present on your own. Designing a 60-90 minute talk forces one to learn the material at a significantly higher level than playing the passive receptive role. Additionally, fellow residents know better how to create a talk that can also be used by the residents later for board review, while the staff don't tend to give a **** about that.

IMHO, giving a reasonable amount of lectures each year is a GOOD thing for residents. Do it yourself, and you'll learn the material better. Have a fellow trainee do it, and you'll have better material to study later. Staff are good at talking about the more complex topics, particularly technique-based subjects. Much better to have a resident do the talk about indications for postmastectomy XRT.

Just my $0.02

 

[radiaterMike]

If you examine the didactic schedules of many other specialties' training programs, you'll find a much richer experience than we have. Might it be a regressive attitude arising from the relatively unique 1-on-1 apprenticeship model we utilize that for the most part medicine has left behind? I honestly don't know.

Perhaps this is more a reflection of your training program than Radiation Oncology training programs in general. I actually think quite the opposite is true. Radiation Oncology residents in some programs are inundated with didactic lectures, in addition to tumor boards.

 

[Adawaal]

Perhaps this is more a reflection of your training program than Radiation Oncology training programs in general. I actually think quite the opposite is true. Radiation Oncology residents in some programs are inundated with didactic lectures, in addition to tumor boards.

Who knows? That's what I've seen in the 25 or so departments I've visited in the past. Plus that's what I hear from residents when I see them at ASTRO, ACRO, etc. Always the possibility of sampling bias....

 

[IndyXRT]

Who knows? That's what I've seen in the 25 or so departments I've visited in the past. Plus that's what I hear from residents when I see them at ASTRO, ACRO, etc. Always the possibility of sampling bias....

That's how it worked during my residency. In general, I also thought I benefitted from compiling lectures, although there comes a point when you become overwhelmed and the learning becomes less high yield.

 

[radiaterMike]

Who knows? That's what I've seen in the 25 or so departments I've visited in the past. Plus that's what I hear from residents when I see them at ASTRO, ACRO, etc. Always the possibility of sampling bias....

Well- the ACGME requires Biology, Physics and Clinical lectures. True- not all places adhere to this requirement, but most do. Most places have grand rounds (cancer center and/or departmental). Many places offer didatics in Statistics (required by ACGME). Lectures in Medical Oncology, Radiology, Pathology, surgery are also pretty standard in many places- either special lectures for Radiation Oncology residents, or the residents attend lectures for fellows/residents in other departments. Many programs send their residents to the Maryland review course, ASTRO refresher course, Osler course, and certainly ASTRO (which has education sessions every morning). Chart rounds are pretty standard- and a necessity for ACR accreditation- many programs use this time to educate residents. Tumor boards- while not truely didactic sessions - are essential education opportunities for residents as well.

I find it hard to believe that other specialties have a "much richer" didactic experience than Radiation Oncology.

 

[CanRadOnc]

From a purely ethical perspective, it is disturbing that your PD is asking you to lie on your reports to the RRC. Ostensibly it is to protect the residents and the program from the consequences but really, it is to protect the attendings who have been very deficient in their responsibilities. I think the RRC is trying to help and protect residents and by "bending the truth" you strip yourself of that.

I agree that by doing presentations themselves, residents get to learn more but only with proper guidance. Maybe the RRC is coming down hard on your program because of the complete lack of academia from the attendings. I had thought that to have a residency program, the center has to have academic production/activities.

The consequences (or threat of) are good motivators to change deficiencies in a residency program. It sounds like your PD is still not motivated enough. Your center may already have a bad reputation in terms of academia.