ACGME accredited fellowship for rad onc

Discussion in 'Radiation Oncology' started by radoncradonc, Feb 10, 2019.

  1. radoncradonc

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    Just heard through the grapevine that my department is trying to start an ACGME accredited rad onc fellowship. Hurray!!! We finally can get better fellowship training now. Rad onc is the new pathology.
     
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  2. domestique

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    what dept are we talking about here?
     
  3. Chartreuse Wombat

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    ACGME does not accredit RadOnc fellowships.
     
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  4. oldking

    oldking Senior Member
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    I wonder how difficult it is to start an ACGME accredited fellowship, especially in a field that has been around for half a century or so and never had (or in opinion needed) one.

    If you’re going to do a fellowship might as well do one that is accredited.
     
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  5. sphinx2019

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    Pain fellowships are accredited.



     
  6. radiaterMike

    radiaterMike Junior Member
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    does not or has not ?
     
  7. oldking

    oldking Senior Member
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    I certainly could be wrong but I thought all “real” fellowships were accredited by the ACGME or another well-established/legitimate body and that only radiation oncology and a few other departments offered “fellowships” with no particular or at least standardized curriculum, evaluation process, etc.

    I can certainly imagine more than a few good reasons why a radiation oncology resident would want to do an extra year of training (extra peds or brachytherapy; major traumatic life event like divorce, death, or injury/illness that precluded giving it ones all and/or caused a significant gap in training; significant other has a year left in training so waiting for them so both can apply for jobs together; or reasonably sure a job will open up next year in ones desired location) ... if that’s the case might as well complete a well structured and accredited fellowship (if one exists) vs some obvious nonsense “fellowship” in “advanced palliation” or whatever.
     
  8. sphinx2019

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    ABR

    Only real fellowship available to rad oncs.


     
  9. medgator

    medgator Senior Member
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    You couldn't pay me enough to do that one. The only thing worse than a palliative RO focused fellowship would be one without any RO focus at all
     
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    #9 medgator, Feb 10, 2019
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  10. Radiator20

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    I didn’t know about that pain fellowship. We are also eligible for the ACGME-accredited palliative care fellowship.

    Other than the above, my understanding is the opposite. All non-accredited, even the well established/prominent ones.
     
    #10 Radiator20, Feb 10, 2019
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  11. RickyScott

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    Besides peds and brachy, there is almost no legitimate reason to do a fellowship given the caliber of people entering this field. Training itself should be 3 years. Even residents at California Pacific, the program closing down, are so much more accomplished than I was. Most fellowships are not posted. Usually the chairman just asks pgy5 to stay? That was my experience. I remember taking real offense to the offer. He may have well asked me to be a fruit picker, but at the time it was a real knock to my WASP privilege. In some departments, like the one I trained in, there is a financial incentive to chairmen to "manage" faculty salaries. Sometimes they get to keep portion of whats "left over", from whatever the university/hospital budgeted for salary. Having a fellow running a service is a great way to do this. How can ACGME ok a fellowship unless it is providing a skill that is not a basic competency in this field?
     
    #11 RickyScott, Feb 10, 2019
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  12. seper

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    True, ACGME does not accredit our fellowships. This can be changed in the future. I wonder what does the process entail? Which RadOnc body would be filing a request to the ACGME? How many years would it take to create a category of ACGME-accredited RadOnc fellowships? I think brachytherapy should be first not peds.
     
  13. Radiator20

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    Certainly agree with these as the two most obvious fellowship choices.

    While the marginal value of proton fellowships has surely diminished over the last few decades with the dramatic increase in proton centers, I believe there are still a good number of programs--even some strong ones--without protons. If anything, having proton exposure during training may be more important than it used to be precisely because protons are now more widespread in practice. I don't think that it would be unreasonable to consider doing a well-established proton fellowship if you lacked that exposure during residency and wanted/expected it to be part of your practice moving forward.
     
  14. Neuronix

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    I know someone who became director of a proton center whose only exposure was a one week training course. Frankly, protons are just not that complicated if you know the fundamentals of radiation oncology. You can learn what you need to know to treat with protons in a rapid amount of time.

    I do not see what you would gain spending a whole year doing a fellowship in protons, other than a way to spend a year if you don't have a job. That written, everyone knows you don't need a fellowship for this, so it's hardly guaranteed that you'll get the job you want after a fellowship (accredited or not).

    With regards to peds... When you look at faculty doing peds out there, even at a high level, many/most didn't have a peds fellowship. Have things become so much more complex with peds that you need a fellowship now where you didn't before?

    I was thinking since I treat a lot of brain and spine: could I do a neuro-oncology fellowship? Our neuro-oncologists don't set foot in the hospital and give a limited number of systemic agents. I feel like I could pick that up what I'd need to know to manage systemic therapies in these patients in a year fellowship. But, there is no pathway for this.
     
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  15. PointA

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    I agree, if you look around the country most peds and proton attendings did not do fellowships. I don't think peds has gotten so much more complex over the past decade and most peds specialists don't have 30+ patients on beam like the rest of us so they have plenty of time to read and consult with other experts about challenging cases. Also spending an entire year learning protons seems like overkill when you can take a month or two of elective time during residency to get that exposure if you really want it. The truth is that for most people, fellowships are just a way to buy time until the desired job opens up. There is actually evidence to back this up also from the RedJ article that showed most people doing peds and proton fellowships ended up taking jobs that don't involve these areas.
     
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  16. oldking

    oldking Senior Member
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    Sorry I wasn’t clear ... when I was mentioning “real” fellowships I meant the dozens, if not hundreds, of legitimate fellowships in other fields that actually provide necessary training in order to be a competent specialists.

    In other words does any field in medicine have “fellowships” like ours that aren’t accredited by the ACGME or another legitimate national overseeing body?

    If so any idea what percentage or if certain fields have more than others? I thought ours was among the only field that has “fellowships” thrown together by individual departments with whatever curriculum, objectives, and evaluation process they want (if any?).
     
  17. Radiator20

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    Many other fields have non-ACGME accredited fellowships. For example, in cards, there are lots of *third* fellowships (e.g., IM -> cards -> interventional -> advanced interventional!) that are non-ACGME accredited. That training pathway seems ridiculous on its face, but I don't know nearly enough about cards to say whether those are viewed as exploitative vs actually necessary for people doing unusual/high-level interventions beyond garden-variety PCI, etc. I don't know enough to comment on the broader landscape of how other specialties' non-accredited fellowships compare to rad onc's, but they do exist.
     
  18. Radiator20

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    Neuronix, I hate to disagree with you, but... I do. Your anecdote is unsettling. I agree one *can* treat with protons with minimal training exposure, but I'm less sure that one should. There are certainly ways to screw up and hurt people with protons. Similar to 3D vs IMRT - at this point we're all aware of how to work with IMRT, but 15 years ago, making that transition successfully was less certain and I think it was appropriate to approach with some caution. I'm not at all saying that proton fellowships are necessary in general, but I do think that some sustained training exposure (even a few months in residency) is wise if you're going to be treating with them.
     
  19. Neuronix

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    Why hate to disagree with me? Please feel free. I'll disagree back. In my opinion, IMRT was far more complicated of a transition from 3D-CRT. So did anyone go and do IMRT fellowships in the 1990s and 2000s?

    Personally, I did spend several months with protons in residency. Maybe I'm on the wrong side of the Dunning-Kruger curve here :laugh:. I just think that there's a limited number of ways that you can hurt people that are specific to protons, and an educational course should cover all of them.

    Example course: PSI Winter School for Protons 2019 (20-25 January 2019) · Indico

    Anyone want to send me to Switzerland? I'll report back on my findings :naughty:
     
  20. Radiator20

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    Because you're usually right! :)
     
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  21. seper

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    Sorry I'll ask again. What is the ACGME process to introduce a new category of accredited fellowships?
     
  22. RickyScott

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    I can attest to that because IMRT/3D basically evolved simultaneously. You had to learn how to contour cross sectional targets, transition from drawing ports. I dont use protons, but if I were at a proton center and did prostate, what exactly I would have to learn, other than how to manage 8-10% late rectal bleeding requiring coagulation, despite space oar/balloons, even when using a pencil beam technique.?
     
  23. Radiator20

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    I mean, based on some IMRT contours and plans I've seen, it might have been better if some people did...

    See, that's precisely my point. Protons do have intrinsic risks that are distinct from photons. It's easy to knock protons in a site like prostate where there are no advantages to counterbalance those risks. On the other hand, there are plenty of situations where protons do have real advantages. But their risks are still there. And making wise clinical decisions in those scenarios is, I think, not always straightforward.
     
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  24. medgator

    medgator Senior Member
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    so, so true
     
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  25. emt409

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    Proton plans are extremely sensitive to depth changes. For example, complex base of skull plans like recurrent nasopharynx can go from safer with protons to much more dangerous if changes in depth (e.g. patient weight loss --> reduction in subq fat) are not appropriately managed.

    I'm not saying a fellowship is necessary, but I think members of this forum thread inappropriately underestimate the amount of nuance in treating with protons.
     
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  26. evilbooyaa

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    The fact that the response to the piss poor job market is to create 'ACGME accredited' fellowships is another example of chairmen and women not giving 2 ****s about the state of the field.

    [​IMG]
     
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  27. RickyScott

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    Intuitively, how much can subcutaneous fat vary when approaching base of skull laterally? 1-2mm. Scalp is only around 3-5 mm thick? I am sure there is some nuance to protons, but I bet you Billy W Loo will also claim "nuance" for his stereotactic fellowship treating lung nodules at Stanford, and may very well feel that he and his proud fellows probably treat lung nodules stereotactically better than anyone else
     
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  28. RO2019

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    To play my normal role of adding in a sense of rationality amongst the crazy:

    - the same fellowship positions keep being posted on the astro site over and over again because clearly they aren’t finding anyone to take it

    - would love to know how many US American grads this year or last year are taking one of these fellowship spots. After all - isn’t that the concern? If it’s just foreign grads taking them, which are the fellows I’ve always been aware of outside those chasing specialized proton training, then no one should have an issue.

    You guys get back to your stuffs
     
  29. CptCrunch

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    I thought some of the neuro onc fellowship programs accepted rad oncs?
     
  30. Neuronix

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    I didn't know that.

    Hmmm... I'm not sure that I want to step back to do a fellowship, but if worst comes to worst...
     
  31. Radiator20

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    And if you're really lucky, you can go to one of the ones that doesn't believe in PCV! Then it could be a whole fellowship for dex, keppra, and TMZ... j/k, sorta...
     
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  32. RickyScott

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    well thats most of them.. only a few give pcv as a "shout out" to the rtog trial in idh+ disease.
    BTW: this was basically similar to the entire field of medical oncology when I was in med school.
     
  33. Krukenberg

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    +1 to this. Rad oncs who haven't trained with protons think because the contouring is the same then there's no extra experience needed, or that all you need is a month or two. Time doing it is less important than the disease sites you've seen and # of cases. Contouring is the same but the technical rad onc-specific management of patients on treatment is very different.

    With each disease site you need to know how frequently on-treatment interval CT scans are needed to ensure the beam isn't totally under- or over-shooting because of patient anatomy changes. Dosimetry will just fuse the current plan on the on-treatment interval CT scan and say "is this good enough" and you need to have a sense of whether it's safe, whether they just need to replan, or whether you have to start from scratch and redraw your contours and replan.

    Experienced centers are now creating 10-12 DVH curves per target and critical OAR by varying setup error in 3D space, and the physician is expected to also evaluate robustness when evaluating plans.

    This experience comes from seeing a bunch of cases with disease site experts who frequently use protons, and managing the patients throughout their course of treatment. Of course if you're going to just work at a prostate proton center you don't need to know how to treat GI, lung, lymphoma, or head and neck malignancies, but then again you'll probably be out of business in a few short years anyway if all the center does is prostate.

    The best training is continuous 4-year exposure to protons in residency to get the longitudinal experience throughout treatment courses, but very few departments in the country have that because the centers are usually far offsite.
     
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  34. radiaterMike

    radiaterMike Junior Member
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    And yet we are supposed to believe that, for prostate cancer, proton therapy is superior to non-proton based IMRT simply because a plan comparison shows that there is less dose exposure to the rectum.
     
  35. RickyScott

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    1) This is likely a bit of an exageration, and wasnt the case 4-5 years ago. Are they adaptively replanning, using space oar, rectal balloons, generating 10-12 DVHS and still obtaining worse toxicity in prostate and lung? Superficially, this sounds like a desperate attempt to save protons. In terms of managing patients on treatment- wouldnt a proton advocate expect them to have less acute toxicity? I could see the need to adaptively replan in head and neck, just as with photons, but replanning is probably no quick matter in these centers. Historically, some could take 3 weeks to do a plan. Has this changed?

    2) "but then again you'll probably be out of business in a few short years anyway if all the center does is prostate." Other way around, multiroom centers will be out of business if they dont treat prostate.
     
    #35 RickyScott, Feb 12, 2019
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  36. Radiator20

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    No. You're not supposed to believe that. No fair-minded radiation oncologist does (though plenty of unreasonable ones may). Again, this is precisely my point. Protons carry their own intrinsic risks that are different from what we're used to with photons. In GU, that's some late rectal bleeding. In NPX? H&N? Spine? Potential for much worse, and evaluating the plan like it's IMRT won't allow you to know those risks or avoid them. Hence why--again--proton training is important if you're doing proton treatment.
     
  37. medgator

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    All the more reason protons should have been just relegated to the 5-10 centers that initially had it
     
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  38. RadOncDoc21

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    Fake News!
     
  39. emt409

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    Scalp only 3-5mm thick? Lol - you are definitely not treating patients in the south or midwest.

    And, Billy Loo was also the first to do cardiac radiosurgery, and probably has a lot to teach. (again, not defending fellowships in general, but just sayin')
     
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  40. Radiator20

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    While I don't know if I'd go quite that far (I think it's reasonable that some new centers should have opened as cost dropped from $150M -> $30M), I won't disagree that proton centers have over-expanded, in many cases by treating patients who are unlikely to benefit and may be harmed.
     
  41. medgator

    medgator Senior Member
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    Patient as well as financial toxicity to the system is certainly something our field doesn't need
     
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  42. scarbrtj

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    Do we know if any of this extra (seemingly frivolous and time-wasting for those of us who are H+ naive) stuff actually does anything for the patients? Data: either LC or toxicity? Or is it just anecdotal and so much mental masturbation. In a way, and I say this non-sarcastically, it's amazing that protons ever cured anybody (especially before the SOBP). I remember in the early IMRT days we had a lot of irrational fears (the fear of motion was over-hyped) that turned out to be unfounded, irrelevant... who's still avoidance contouring the patient's lips for oropharynx/larynx cases?
     
  43. medgator

    medgator Senior Member
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    I do oral cavity.. Try to push dose out in other directions when I can
     
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  44. evilbooyaa

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    Standard avoidance structure, contoured by dosimetry, for every H&N plan involving treatment of primary or coplanar lymph nodes (level 2). Doesn't mean beams are necessarily vectored out, but dose is limited to that region.
     
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  45. Krukenberg

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    All I'm addressing is the extra work and training experience that is needed to ensure a safe proton plan and delivery. Prostate is the simplest site to treat which is partly why it's such a cash cow. Other disease sites create significantly more physician work because of the steps I described previously.

    Not an exaggeration, and everything I've described is extra work that is needed to ensure that the proton dose is going where you want it to go. Whether the dose going where you want it to go can reduce toxicity is beyond the scope of what I'm talking about. Centers that are using robust optimization have the capability of generating DVH "uncertainty" curves. You'd be shocked at how wide the gap is between the curves for a plan that is generated without robust optimization.

    Agree. The physician work from contour approval to the end of treatment is very different for protons and if treated the same way as IMRT can lead to target misses and OAR overdosing.

    No one knows if it's any better. I'm just saying that is all the extra work involved to ensure that the dose you delivered over the course of treatment is substantially similar to the plan you generate from sim. If anything all of this makes protons far more unsafe if corners are being cut or inexperienced physicians are managing the patients the same way they would an IMRT patient.
     
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  46. medgator

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    Something to think about with the rapid proliferation in centers over the last decade :xf:
     
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  47. Krukenberg

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    Definitely concerning.
     
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  48. Mr RADical

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    prime example is the "learning curve" that was seen in the Liao trial:

     
  49. RickyScott

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    Would be interested to know if they were replanning and adapting the protons, but not the IMRT,
     
  50. Neuronix

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    As I mentioned, I did train with protons. Where I trained they have had a proton fellowship for years. Up until recently they didn't have pencil beam and therefore didn't even discuss robustness outside of occasional lectures.

    PS: I contour oral cavity and lips routinely for H&N cases.
     

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