What is/was your Residency Experience Like?

[RaydOnc]

Hello,

I'm a new PGY-2 and have some concerns/issues regarding my residency program. I was wondering if any of you current residents or recent graduates would comment on some of these issues:

1. Balance of clinical workload & education -

• Our center is a high-volume facility with more patients to be seen than residents available. During the day, I see 2-4 consults, and 8-10 follow ups.
• My concern here is that the follow-ups are not as educational - e.g. prostate cancer s/p EBRT 2 years ago. Assessment & Plan: increase Tamsulosin. PSA today 0.1. RTC 6 months with PSA
• Treatment check days are usually the least educational - I see most of the on-treatment patients where very little is actually learned by seeing the patients.
  
• The number of follow-ups is increasingly overwhelming and that cuts into my time for consults: in terms of preparation, reading, discussing the case at length with the attending, etc.
• I end up staying late dictating notes (until 6-7 PM) just because of the sheer volume of patients
• I understand that being inefficient as a new resident might be a confounding factor
• I think seeing follow-ups & OTVs, are not as high-yield for learning
• Again, don't get me wrong, even treatment checks can be a learning opportunity (Management of Grade 2 dermatitis after 60 Gy for H&N, skin checks for breast patients, etc) and when that does occur, I make the most of it; but majority of the time, they are not.
  
• Does your residency programs ever make use of mid-level providers (PA or NPs) to help see the routine follow-ups & treatment check?
• At our institute, there are far fewer residents than attendings and no mid-levels. Are they routinely employed in rad onc?

2. Dosimetry & Treatment Planning -

• Once I finish the contours and write the prescription for an IMRT plan, I've no idea what happens in the treatment planning room/dosimetric/physicist QA analysis. Our attendings, although they review some of the contours with residents at our request, do not involve residents in the dosimetry/treatment planning process. Instead we are delegated to see the treatment checks and follow-ups.
• I've a strong feeling that a major part of what radiation oncologists do - occurs in the planning room (verifying dose homogeneity, conforming DVH constraints, setting wedges to smooth out isodose lines, skin bolus, etc.) - all of which is not taught upfront.
• We have a dedicated 1 month combined Dosimetry/Physics rotation that happens sometime PGY-4 year
• I wish we were allowed to sit in with the attendings when treatment planning occurs everyday, instead of just 1 month.
• I've tried doing this, but within 5 minutes of sitting down with the attending & dosimetry, I get paged about a patient that needs to be seen (OTV or follow up)
• This would be another opportunity where, if a mid-level were employed seeing the uncomplicated followups and OTVs, residents would be free to learn some of the most interesting & challenging (in my opinion) aspects of RadOnc
• Does your residency program allow for residents to learn dosimetry & treatment planning early on?

3. Multiple Attending Coverage -

• Sometimes we cover more than one attending
• This includes seeing all of their consults, OTV, follow ups, CT Simulations, etc.
• I love that we have so many patients and the clinical breadth & depth are definitely a strength of our program
• However, to some extent, this compromises my learning opportunity with each & every consult or CT Simulation
• E.g. The other day, I was covering another attending who had an angiosarcoma consult which I had to see - I was excited to see the rare disease, but at the same time, had very little time to prepare for the consult, read up on the literature and learn from the radiation planning.
• I also get the continuous feeling from attendings that the sole purpose of a resident is to make attendings' lives easier - education takes the backseat. E.g. We had a great physics lecture early one morning and we were late to clinic by 30 minutes because the lecturer went over his allocated time. The next day we get an e-mail from the program director that didactics should only be held after clinic hours and is not an excuse for coming late to clinic
  
• Attendings don't usually see patients on their own, even when I have 2 patients to present and 3 additional patients in the waiting room
• Does your program have multiple attending coverage?
• If so, would it be wrong to discuss this issue with program director/chairman to limit 1:1 resident:attending coverage?

4. Academic Time -

• Our attendings do have their half day/full day academic time, however, since most of the time we are covering 2 attendings, the other attending is seeing patients the same day and therefore we technically never end up getting protected academic time
• We usually have our didactics (radbio/physics) in the late afternoon/early evening but are required to return to clinic if they finish early or are cancelled.
• Does your program have a dedicated academic time for residents?
• Let me clarify what I mean by that: protected time, free from patient responsibilities, in addition to didactics, that allows residents to contour, read and understand clinical oncology, engage in research, learn dosimetry/planning, etc.

5. Chart Rounds -

• Our weekly chart rounds are long in duration due to the number of patients and often lasts 2-3 hours
• Attending presence is quite dismal and can be anywhere from 1-2 attendings
• Very little is actually taught/discussed by the few attendings who are there
• We have a great physicist who sometimes highlights the nuances of physics during chart rounds, but that too is rare
• How much education/learning do you get from chart rounds at your program?

6. Attending Didactics -

• Most of our clinical didactics are lead by residents without attending presence
• Looking at last year's schedule, we had 3-4 attending didactics about clinical topics the entire year
• How often do attendings formally lecture/teach at your program?

7. Contouring -

• I've tried contouring in between seeing patients, but there is rarely 5 minutes between patients
• I don't eat lunch most days because of patients/contouring
• Since we don't have academic days, most of the contouring takes place after hours (after 6 PM)
• When do you guys find time to contour?

8. Misc -

• I've discussed the above issues with other PGY2, PGY3, and PGY-4 residents at our program and they all, individually, agree that things could be improved - but no one is willing to sit down with the program director/chair to discuss the issues.
• Most residents are worried that if we do bring up some of the above issues, they will get negative feedback/performance reviews, which ultimately might affect their promotion to the next level and/or future job prospects
• We have one chief resident, but since he is interested in academics and wants to stay at our center next year, I doubt he would be willing to go bat for us residents

I know what some of you are thinking - suck it up, you pansy! Stop complaining! Atleast you get weekends off and aren't working 120 hours/week like surgical residents do. And you are right, I'm so grateful for weekends, I would go crazy without them.

But at the same time, residency is the only time I get to learn most of what I need to know to become a successful attending. I'm worried that if things continue the way they do, I would not be able to learn as much and as well as I'd like. I want to make the most of my residency experience and instead of helping me do so, I'm worried that my program will hinder me from doing so.

Since I didn't do any away rotations before matching at my top program and don't know what its like at other programs, I'd like to hear from other residents about how their program handles the aforementioned issues.

I'd also appreciate it if recent graduates and attendings to comment on the above. Are some of these issues that I should be concerned with? And if so, would it be worth talking to the program director to help improve the program? Or should I just follow our chief resident's advice "things are going to be ok, we all made it."

---

Members don't see this ad.

 

[Linaculous]

I'm sorry, I don't have anything of substance to add. I just wanted to say that this is scary to read. As a pgy1, I feel like my program could be like this and I'd never know until it's too late. I realize why people don't want to name names, but I wish there was more information out there about which programs are like this and which aren't.

 

[thecarbonionangle]

I'm sorry this is happening to you. I can only tell you that you are NOT alone and a few people are in for a big surprise when they start on PGY2. I am very thankful to have done 4 away rotations. In two of the "mid-tier" institutions that i rotated in, this was a big problem. The residents often left around 7-8pm. Dictating all day or sometimes contouring so much (8 head and neck sims not unusual). Zero time to actually learn. Almost no lectures, and very little time to learn how to be a radiation oncologist. A few of the residents were secretly looking into transferring out. Needless to say i will be ranking these programs very low.

 

[Neuronix]

My personal belief is that the "tier" of the program has little correlation with the educational experience of the residents. There's not a whole lot of data on this, but here is the little bit we have: http://forums.studentdoctor.net/thr...onc-where-does-your-program-stack-up.1043268/

Specifically:

• Does your residency programs ever make use of mid-level providers (PA or NPs) to help see the routine follow-ups & treatment check?

Yes we do employ PAs and NPs and residents are not expected to see every OTV and follow-up. It's important as a resident to see some follow-ups and OTVs. Learning value isn't high after you see a number of these. I do think it's good to look for a residency program where residents are not expected to see every routine case.

Does your residency program allow for residents to learn dosimetry & treatment planning early on?

Yes. We have a dedicated dosimetry rotation as a PGY-3. As a PGY-2 I was already planning simple things however and I felt comfortable planning IMRT as a PGY-3. The early experience is in part because we do a lot of breast and prostate the first year. As you surmised, we have NPs and PAs to help us with those routine follow-ups, which gives us time to plan out these patients.

Does your program have multiple attending coverage?

• If so, would it be wrong to discuss this issue with program director/chairman to limit 1:1 resident:attending coverage?

Rarely. I agree that programs should be 1:1 coverage except in special cases like 2 part-time attendings.

Does your program have a dedicated academic time for residents?

Yes, 1-2 days on every rotation. I also think this is important for reading and thinking. Patient volume is important, but so is time to read, think, be thorough and meticulous in your work, and produce research. I think it should all be balanced as a resident. Not enough patient volume and you don't learn patient care. Too much patient volume and you don't learn patient care either because you don't learn the fundamentals of the specialty and become an algorithm machine. Sure, as a private practice attending you may become a high volume algorithm machine, but residency is the time to truly learn the field, not prepare for private practice.

How much education/learning do you get from chart rounds at your program?

It's not great, and I do think it has been a weakness of our program. Some programs are better at this. Attendings often just want to get in and get out. Chart rounds should be about pointing out the important parts of treatment planning, evaluation, and organs at risk, so I often ask questions about these things.

How often do attendings formally lecture/teach at your program?

Agree that this is poor form. The residents often, though not always, lead lecture, but an attending is always present. Residents teaching residents is simply the blind leading the blind.

When do you guys find time to contour?

Depends how busy we are. Certainly plenty of late nights for me and sometimes weekends depending on how busy things are.

Since I didn't do any away rotations before matching at my top program and don't know what its like at other programs, I'd like to hear from other residents about how their program handles the aforementioned issues.

It does vary quite a bit. I rotated at two top tier residency programs that everyone on SDN swoons and had a lousy time. The residents were miserable and felt undereducated and underappreciated. I enjoy my program quite a bit and tell the med students who away rotate and interview here as much. We have a reputation for having happy residents, and I hope well educated residents. I still think this is underappreciated by MS-4s who are often looking for prestige and location primarily.

And if so, would it be worth talking to the program director to help improve the program?

You can try. I doubt it will change much, and I agree it could backfire and make you look bad. You're cheap and you have no power. The field is very small so it's difficult to switch programs. PAs, NPs, and extra attendings cost a lot of money and will put up boundaries against things like overwork. Many programs combat this by trying to expand their residency programs, which costs them next to nothing, especially when they give their residents no resources and expect them to work all the time. It seems good in the near-term, because the workload is spread among more people. But it's bad for the residents in the long run because of job saturation.

 

[ramsesthenice]

I genuinely think a lot of what you are feeling will get better. Your first year you have to get used to a certain amount of having no idea what is going on around you. You could read all day long and still not appreciate a lot of what is going on around you. It takes experience apprceciate what is going on behind the scenes with physics and dosimetry and you will get that in time. Same for all things clinical.

You are going to stay well past 500 most days each week. Its residency, not the golf-get-away everyone else thinks it is. We have a generally great residency (see below) but Im still here from about 645 am until 630-700 pm two or three nights per week to finish notes and contour on busier services. Even on slacker services still here until around 600 on clinic nights.

We have very minimal cross cover (< 1 day per month) and we get 2 academic days per week. Its awsome, but there are very high expectations for us to publish and do things with those academic days. I know its different, but I am almost as busy on academic days as clinic days. A lot of programs are like yours as far as cross cover and having no academic days. No doubt it keeps you busy, but as you get the hang of things it will get better.

We do have NPs. On two of our services we couldn't do without them. Our H&N service (with one attending) sees 4-6 consults and 10-15 follow ups each clinic day sprinkled with status checks for the 25-40 patients under treatment over two days. One of our thoracic attendings is just as busy and uses and NP as well.

 

[ramsesthenice]

Oh yea, meant to say, our chart rounds have pretty useless for learning. Residents are expected to run it, meaning get the images projected up and keep opening the right files and present all the patients (even the ones you don't know). Ours is at noon so at most 2-3 residents make it because of clinic which means when your there you are not looking at anything, you are presenting, clicking buttons and listening to people tell you, "looks fine, next..."

Fortunately our Junior faculty are changing that. They were horrified by how little our recent seniors were able to evaluate ports etc. So...we are moving to a morning time. Hopefully that will help some. It is a good chance for learning.

 

[Neuronix]

Oh yea, meant to say, our chart rounds have pretty useless for learning. Residents are expected to run it, meaning get the images projected up and keep opening the right files and present all the patients (even the ones you don't know). Ours is at noon so at most 2-3 residents make it because of clinic which means when your there you are not looking at anything, you are presenting, clicking buttons and listening to people tell you, "looks fine, next..."

We have a dosimetrist do the clicking part so that residents can focus on discussing and evaluating plans. That seems like it would help?

 

[ramsesthenice]

We have a dosimetrist do the clicking part so that residents can focus on discussing and evaluating plans. That seems like it would help?

We have one there too but it's a two man job because a third of our plans are tomo. Again, moving to the morning will help because more will be free. The biggest impediment is having to present other resident/attending cases. Your just reading planning notes and not even looking at the plans. Having everyone there will fix that. It's a good move.