research in radonc

[eidolon]

hopefully rather than being an exercise in silliness, this will generate some discussion:

1. why is it that radiation oncologists tend to publish more in the clinically oriented journals such as the red journal, NEJM, JAMA, etc. rather than journals like Nature, Science, Cancer Cell, etc.?

2. how come there isn't a single radiation oncologist on the "big name" list who has HHMI funding or who is a member of the National Academy of Science?

does this mean that rad onc as field is not very supportive of people who want to pursue basic science?

curious to hear what people think on this subject

---

Members don't see this ad.

 

[radonc]

hopefully rather than being an exercise in silliness, this will generate some discussion:

1. why is it that radiation oncologists tend to publish more in the clinically oriented journals such as the red journal, NEJM, JAMA, etc. rather than journals like Nature, Science, Cancer Cell, etc.?

2. how come there isn't a single radiation oncologist on the "big name" list who has HHMI funding or who is a member of the National Academy of Science?

does this mean that rad onc as field is not very supportive of people who want to pursue basic science?

curious to hear what people think on this subject

well, i would like to point out in 2005, there were 138 radonc positions (pgy1 + 2) out of 24,012 total residency positions offered. that means that radiation oncology only makes up 0.57% of all of residency positions in 2005. extrapolate that to all physicians in the country...that number cannot be more than 1% [of all physicians are radiation oncologists].

then throw in the fact that radiation oncologists have traditionally been overshadowed by their surgical and medical oncology colleagues, and their supposed role as 'palliative' doctors.

one reason we publish in clinically oriented journals is because that what a lot of physicians are pursuing. many nih/nci funded grants fund translational/clinical research. the bench research in radonc isnt suitable for nature/science due to the focused nature of the research on various radiation physics techniques, advances in radiation biology, etc...plus those journals publish mostly non-medicine related research like geology, marine biology, astronomy, etc, etc.

 

[RadOncMan]

Radiation Biology, particularly in areas such as DNA repair or discovery of a novel oncogenes or tumor suppressors that for example are radiation induced or work in radiation-induced DNA damage pathways can definitely be published in top journals.

I also don't quite understand why there is a such a paucity of top notch basic science/translational research in Radiation Oncology compared to Medical Oncology. Perhaps Radiation Oncologists are so focused on details of clinical trials, they can't see the forest from the trees. Or maybe Radiation Oncology just hasn't attracted any of the most promising physician-scientists until more recently, and when they do, their creativity and imagination is somehow suppressed by the nature of the clinical work.

Even amongst the top Radiation Oncologists who focus predominantly on basic science research, I don't think you can mention ANY of them in the same breadth as the top Medical Oncologists. Most would be second rate if you judged them purely on their research. Can you imagine any Radiation Oncologist meriting a job offer from i.e. Rockefeller or the Whitehead Institute? On the other hand, look at the publications of someone like Dan Haber or Charles Sawyers. Or compared to a pure basic scientist like Dave Allis (39 publications in science, nature, or cell) or Nikola Pavletich.

Personally, I don't think most clinical Radiation Oncolgists recognize or appreciate the time commitment necessary to produce top level basic science work. Anyone thinking they can spend less than 75% of their time on research and regularly publish in Nature is kidding themselves. And there just isn't that type of commitment from department chairs because of interest in bringing in revenue from clinical work.

 

[eidolon]

i wonder if the high reimbursement in radiation oncology discourages people from pursuing research?

granted that basic science research can be more time consuming than clinical projects, often by orders of magnitude. is it possible for someone to extend one's residency training to get more research time, i.e. as commonly seen in heme/onc specialty? if possible, why isn't this route more utilized? if one were to pursue this route, is there any downside other than the deferred income?

any thoughts?

 

[Doctor&Geek]

I'm sure you are aware then of the Holman Pathway, an ABR-approved special residency pathway for Radiology and Radiation Oncology which increases and consolidates protected research time and provides funding for a resident to pursue his or her research interests. In the pathway, you will not need to extend your residency time.

http://www.acgme.org/acWebsite/RRC_430/430_holmanPath.asp
http://www.theabr.org/RO_Holman.htm

In addition, you could always do a postdoc, or if you're really lucky, obtain an instructor position that is like a postdoc but pays better (but you need your own funding).

The disadvantage to the Holman Pathway is that you may have less training (350 external beams cases versus minimum 450 external beam cases in residency), and that in order to accomodate your special interests, your fellow residents and the faculty may have to stand in for you.

It seems obvious to me that if one is interested in translational or basic science radiobiology or physics that this pathway is not only suited but should be more actively encouraged for residents. However, from reading on this forum in other posts and speaking to several faculty, my (perhaps misinformed) feeling is that many clinical faculty including some program directors feel that the Holman Pathway shortchanges clinical training for the trainee and puts hardships on the other residents.

It seems to me that unless one goes to several specific programs, faculty may give lip service or may really want to see research from residents, but very few would be willing to let trainees give up the time or provide the resources necessary to obtain K08 or similar grants, leading to an independent, R01 funded research laboratory. Please, please correct me if I'm wrong with this regard.

If I may be so bold, but the question is begged - if research is so important for obtaining a residency position in radiation oncology, why aren't more residents and young faculty following the general and accepted model of the 80/20 or even 60/40 physician-scientist? The proportion of MD/PhD residents in radiation oncology is very high (double that of the next highest specialty) - why hasn't this resulted in an increase in the number of young physician scientist radiation oncology faculty? Is this because residency programs are unwilling to support opportunities such as the Holman Pathway or anything else that helps trainees become independent investigators? If so, all that money that the NIH provides to train MD/PhD students is a waste, and their PhDs are basically useless.

Finally, I see no reason why radiation oncologists are not ideally placed to be physician scientists, nor do I see any reason why a radiation oncologist doesn't have the background to perform research at the same level as that of a medical oncologist. It seems to me that radiation oncology suffers the same problems as that of the surgical, procedure-based specialties. Those specialties interestingly do not attract as many MD/PhD students as Radiation Oncology does, but the inherent problem is the same - how do residency programs cope with supplying residents with opportunites for significant research while at the same time providing solid clinical training and servicing patient volume?

 

[landon]

Radiation Oncology, resident research, and the American Board of Radiology Holman Pathway

Int J Radiat Oncol Biol Physics
2005;62:623-5.

 

[RadOncAnon]

We have to be trailblazers if we want to do a significant amount of research in RadOnc, that's the bottom line.

Unfortunately, the RadOnc residency model at many institutions is ill-suited for providing significant amount of bench time. Given the very small # of residents/year (1 or 2 at most places), attendings require us to run their clinics. In the case of internal medicine, you are dealing with a much higher volume of residents so what's one less in the lab?

Another problem is the disconnect I have observed between chairs and the rest of the faculty. Often, the chair has a sizable lab with little or no clinical time. This fact, coupled with their position as individuals who provide the department with "vision for the future," make them more amenable to taking applicants with a PhD or strong research backgrounds. However, the reality of the clinic will always rear its head. At one place I interviewed, the chair assured me oodles of time for bench work (this particular place was quite strong in that arena). Mere minutes laters and mere feet down the hall, another attending told me that four months maximum was all the program could provide.

In the last 15 years or so, nearly all major innovations in RadOnc have come from the physics side of things. With the development of IMRT, full-body radiosurgery and, most recently, IGRT the field is advancing quickly. However, many physicists I talked to say that this is the end of physics innovation for a while (barring any radical pardigm shifts). Thus, it is time for radiobiology to rise up from the ranks of the red-headed stepchild of RadOnc research. Unfortunately, many radiation oncologists think radiobiology is limited to, "what happens if I combine this [antibody, FDA-approved drug, novel compound] with radiation in a Phase I trial?" In other words, there is a paucity of research on the molecular mechanisms of radiosensitization and rational design of new sensitizers (or protectants for that matter).

Then why are there so many MD/PhDs in RadOnc? Simple really -- because that has how competitive things have gotten. Some people simply can't grasp the reality that program directors have to cope with. There are literally hundreds and hundreds of well-qualified applicants at many big programs. All things being equal, why in blue blazes would you not choose someone with 3+ years of dedicated research? Since RadOnc is an evidenced-based field, a PhD is seen as a proxy for academic potential.

So, after all this, do you still want to do bench research in RadOnc? Here are some ways you can stack the deck in your favor:

1. Go to a place where residents are not indispensable for the clinical work they provide to attendings. This may be difficult to gauge at some places -- definitely trust the residents opinions on the matter > faculty opinions.

2. Go to a place where everyone is on the same page. It's all well and good if the chair provides you with dedicated research time -- but if you piss off all the other residents and faculty in the process, you will be in for a miserable four years.

3. Try to avoid places that hemorrhage residents into private practice (e.g. virtually 100% of residents do not go academic). In my experience, research-minded residents that go into these programs tend to be hypnotized by the money-making potential of private RadOnc fairly quickly.

4. Ask about Holman, if you dare. Some programs will love you for it and others will throw your application in the trash.

The sad reality is, RadOnc is so competitive now that most applicants will not have the luxury to throw in these caveats. I have to admit that when I started the whole application process, I was very gung-ho about RadOnc and I still am for the most part. But I wonder to myself as Match Day approaches if would not have been better served going into Hem/Onc instead.

 

[cdf95cro]

I agree that most recent innovations have come from the physics side; however, these advances are not due to a glut of research oriented physicists. I'd attribute them to the fact that we can now do inverse planning, a previously diffficult computational step, in near real time. So, the "discovery of IMRT" is really just computing power reaching a point where we can implement it. After all, the concept of conformal therapy has been around for decades...we just had to wait for Moore's law to catch up.

So, essentially, I'd say the same is true for Hem/Onc; genomic and pathway knowledge has now reached a point where it can be exploited to use new drugs. People have been taling about "targeted antibodies" for at least 2 decades, but only now are they being used.

Thomas Kuhn's Structure of Scientific Revolutions ( a great read) stipulates that science in any field advances in fits and starts. So, a "stabilization" period is not one in which innovation is static, but one where collectively a group waits for the data to catch up with the innovation.I think that, more than a dearth of researchers, is what has happened recently in Rad Onc. We are still getting a grasp on the implications of new technology, and this must stabilize before we innovate again.

Additionally, Moore's Technology adoption curve (http://ist-socrates.berkeley.edu/~fmb/articles/lifecycle/) provides a useful metaphor for the implementation of scientific discovery that we see clinically (presuming of course, the new technique/drug/machine/protocol is actually better in some way). That is, it takes time to evaluate novel ideas and test them...this should not be misconstrued as scientific inactivity.

Finally, I agree that "We have to be trailblazers if we want to do a significant amount of research in RadOnc, that's the bottom line." This is true for every generation of physicians, even in small fields like ours- if we want patient outcomes to improve, we need to develop a culture that supports research in both clinic and bench arenas. What's funny to me is that several PDs I've met feel this is a great time to be young and in research because we are on the cusp of discoveries, and all the research backround applicants have means greater capacity to discover new ares to investigate.

One big concern for me is the "what happens if I combine this [antibody, FDA-approved drug, novel compound] with radiation in a Phase I trial?" issue. While I disagree that " there is a paucity of research on the molecular mechanisms of radiosensitization and rational design of new sensitizers (or protectants for that matter)" after ASTRO/RRS this year, I am troubled that there is such easy Big Pharma funding available for novel drug studies, and so little research support from institutions or study sections for radiobiology.

 

[stephew]

the holman pathway is not championed by chair, so be careful if youre on the trail touting it.

 

[Gfunk6]

the holman pathway is not championed by chair, so be careful if youre on the trail touting it.

"not championed by chair?"

Do you mean the chair at Harvard or chairs in general?

If the latter, why is that?

 

[stephew]

"not championed by chair?"

Do you mean the chair at Harvard?

nope not harvard. it was invented here ergo we like it. i meant to say "by all chairs"

 

[Doctor&Geek]

There ought to be some way to just get chairs and PDs to say "yes" or "no" on the question of the Holman Pathway or at least some information on the order of "x months guaranteed protected time for research" (for qualified applicants).

 

[stephew]

well really holman and research are two diff't things. Wait that didnt sound right. What I mean is many chairs would love you to do research but don't like the holman pathway; so you might consider asking the residents and in general about research opportunites to feel things out.

 

[eidolon]

well really holman and research are two diff't things. Wait that didnt sound right. What I mean is many chairs would love you to do research but don't like the holman pathway; so you might consider asking the residents and in general about research opportunites to feel things out.

can you elaborate more on why most chairs do not support the holman? if most chairs don't support it, how did it come into existence anyhow? and would residents who participate in the holman pathway be at a disadvantage when looking for jobs later if most chairs don't believe in it? it seems somewhat paradoxical and unrealistic if most programs love for the residents to do research yet does not provide them with sufficient protected research time (the longest i'm heard is a year).

 

[eidolon]

well really holman and research are two diff't things. Wait that didnt sound right. What I mean is many chairs would love you to do research but don't like the holman pathway; so you might consider asking the residents and in general about research opportunites to feel things out.

can you elaborate more on why most chairs do not support the holman? if most chairs don't support it, how did it come into existence anyhow? and would residents who participate in the holman pathway be at a disadvantage when looking for jobs later if most chairs don't believe in it? it seems somewhat paradoxical and unrealistic if most programs love for the residents to do research yet do not provide them with sufficient protected research time (the longest i'm heard is a year).

 

[Doctor&Geek]

Perhaps one possible solution is to allow the opportunity to *fund* (keyword) an additional year in residency with protected research time and clinic continuity (in the classic 80/20 distribution). Medicine fast-tracking programs with 2 years of protected research time take at least 6 years to complete - so the lengthiness is not unusual. Other procedure-heavy specialties, such as general surgery, also support funded research fellowships. In my mind, some sort of bridge funding supporting a "postdoc" year towards a research faculty position elsewhere might be acceptable to all parties.

The concern is that unless one is incredibly lucky or is directly continuing previous research, one year of protected time (and likely 0-1 first author publications) is not going to cut it when attempting to obtain "reasonable" faculty positions. And you can forget about starting a translational or basic science lab if one only has four to six months. The average basic scientist needs 5 or 6 *years* of postdoctoral fellowships to get the opportunity to start his or her own lab - it strikes me as wishful thinking that five months of bench research would result in a chance to make real advances in treatment. Finally, I also doubt very highly that high-powered mentors (outside of the radiobiology divisions of radiation oncology departments) would take on residents for what amounts to be a "rotation".

 

[Ursus Martimus]

Perhaps one possible solution is to allow the opportunity to *fund* (keyword) an additional year in residency with protected research time and clinic continuity (in the classic 80/20 distribution). Medicine fast-tracking programs with 2 years of protected research time take at least 6 years to complete - so the lengthiness is not unusual. ...The average basic scientist needs 5 or 6 *years* of postdoctoral fellowships to get the opportunity to start his or her own lab.

Although much of this is true, I think the approach is much too simplistic First off, unlike many medical specialities, radonc is less time comsuming (not necessarily easier, as much of medicine is about sitting around waiting.) This provides the opportunity to "sneak more hours into a day, and more days into the week. For instance most programs allow for an "academic day" this coupled with generous call schedules in most progrms allowing for generally free weekends adds nearly 3 days to your week. 4 days in clinic and 3 days in the lab is pretty good. Sure there is lots of reading for Radonc - but this again is not unusual fro physician-scientist.

If one elects for a program that gives a large chuck of time for research, 9-12 months- on top of the 3 days per week the time begins to add up. As well some programs, ie U of Wisconsin do indeed encourage their residents to obtain NIH K-type grants with which they can hire an assistant. If the reader's basic science experience was anything like mine, It is not unusual for there to be >6 hours of "grunt work" for every hour of thinking. If you have an assistant "grunting" while you see patients that increases your efficiency further. After all, very few successful basic scientist ever touch a pipetter anymore.

As we all know the reason why basic scientists take longer to establish themselves is they are expected to bring in grants and do not have the luxury of "billing" to help earn their keep.

I do think that we will see a change in the field. It is indeed because of the "life-style". How you decide to spend your freetime, on the golf course or at the bench will help determine how successful you will be at managing being a physician scientist. You must admit there is no comparison between what radonc offers as compared to someone with similar goals pursuing surgical training.

 

[trublu]

First, I'd like to say "thanks" to the above contributors for fueling what I think is a great thread.

Second, I think it's appropriate to acknowledge that there are some fantastic researchers in the field who, though they're not (yet) HHMI or NAS, are accomplished and well-published. Science , Nature, and Cancer Cell all pop up during lit searches of rad onc topics, owing to the work of some great investigators such as Fuks, Kolesnik, Jain, Giaccia, Dewhirst, etc.

Third, I think the rad onc representation amongst "cream-of-the-crop" research is likely to become more prominent as the now young MD/PhDs and research-minded MDs in the field mature. It seems to me that modern trainees view success in science differently (i.e. Nature, Science, and Cell, rather than Red Journal) - this thread, alone, is evidence of that. Higher expectations tend to bring higher achievements, in my experience.

Finally, I would echo what has been written in above posts by predicting that as radiobiology emerges as a force to shape clinical practice over the next generation, our science will improve. But not before then. We will need to demonstrate that the 80% clinical time sacrificed to basic research readily benefits the patient before chairmen will devote the time/funds/resources to improve our science to the point where it can readily benefit the patient.

Wait... That doesn't sound right...

 

[Doctor&Geek]

Although much of this is true, I think the approach is much too simplistic. First off, unlike many medical specialities, radonc is less time comsuming (not necessarily easier, as much of medicine is about sitting around waiting.) This provides the opportunity to "sneak more hours into a day, and more days into the week. For instance most programs allow for an "academic day" this coupled with generous call schedules in most programs allowing for generally free weekends adds nearly 3 days to your week. 4 days in clinic and 3 days in the lab is pretty good. Sure there is lots of reading for Radonc - but this again is not unusual fro physician-scientist.

If one elects for a program that gives a large chuck of time for research, 9-12 months- on top of the 3 days per week the time begins to add up. As well some programs, ie U of Wisconsin do indeed encourage their residents to obtain NIH K-type grants with which they can hire an assistant. If the reader's basic science experience was anything like mine, It is not unusual for there to be >6 hours of "grunt work" for every hour of thinking. If you have an assistant "grunting" while you see patients that increases your efficiency further. After all, very few successful basic scientist ever touch a pipetter anymore.

As we all know the reason why basic scientists take longer to establish themselves is they are expected to bring in grants and do not have the luxury of "billing" to help earn their keep.

I do think that we will see a change in the field. It is indeed because of the "life-style". How you decide to spend your freetime, on the golf course or at the bench will help determine how successful you will be at managing being a physician scientist. You must admit there is no comparison between what radonc offers as compared to someone with similar goals pursuing surgical training.

Your point is well taken, and certainly if you're supplied with a technician, that would help tremendously. However, most scientists would argue for more protected time. 50/50 (in reality much less than this) is pretty tough to maintain a productive project - if you're a resident or faculty without tenure you still need to spend a lot of time in the lab doing grunt work in order to get an R01. Obtaining a K-type grant isn't as simple as writing up one without any preliminary data, and there aren't that many institutions that are willing to give you space and are willing to pay for technicians on the basis of short-term research projects during residency that you'd like to continue. Finally, while as a clinician one might be able to support his or her own research through clinical volume, if one wants to be a 80/20 physician scientist, its going to be very hard to negotiate a salary commensurate with a full-time clinician, unless one has the grant support.

I do admit that radiation oncology offers more time for research training than say, general surgery. But then again, there aren't that many successful physician scientists in general surgery, and empirically, there aren't that many physician scientists in radiation oncology either. There are many more successful physician scientists in medicine or pediatrics, even whilst the amount of work hours these physicians spend per week exceeds that of radiation oncology. If radiation oncology physicians have more time to pursue their academic interests that arguably any specialty, then there is no reason why the 80/20 model intrinsically won't work.

 

[Doctor&Geek]

Second, I think it's appropriate to acknowledge that there are some fantastic researchers in the field who, though they're not (yet) HHMI or NAS, are accomplished and well-published. Science , Nature, and Cancer Cell all pop up during lit searches of rad onc topics, owing to the work of some great investigators such as Fuks, Kolesnik, Jain, Giaccia, Dewhirst, etc.

I'd like to point out that of your list, only Dr. Fuks is a practicing radiation oncologist and has a lab. (Actually, I'm not sure about Dr. Kolesnik). I hope to see more people like Albert Koong,

http://radonc.stanford.edu/radtherapy/faculty/koong.html

but upon looking, finding people like him is tough. A lot of the top research in DNA damage isn't done by radiation oncology departments, either.

Finally, I would echo what has been written in above posts by predicting that as radiobiology emerges as a force to shape clinical practice over the next generation, our science will improve. But not before then. We will need to demonstrate that the 80% clinical time sacrificed to basic research readily benefits the patient before chairmen will devote the time/funds/resources to improve our science to the point where it can readily benefit the patient.

Wait... That doesn't sound right...

Well, again, by that rationale, chairs of medicine and pediatrics departments wouldn't be supporting translational scientists, let alone basic scientists.

A number of publications are listed here that speak to this issue:

http://www.physicianscientists.org/Publications.html

 

[pook]

Scientist and clinician

http://info.med.yale.edu/therarad/faculty/glazer.html

 

[RadOncMan]

Scientist and clinician

http://info.med.yale.edu/therarad/faculty/glazer.html

If this is the best that Rad Onc has to offer, then the field definitely has a long ways to go in producing the best physician scientists. I wish there were some role models to look up to for up and coming Radiation Oncologists. Unfortunately I don't think there are any.

 

[RadOncMan]

From what I know Kolesnick is a research only guy... and not even a Radiation Oncologist. He's probably the only guy mentioned here whose work I really respect.

Look at it this way. Pretend you are a PhD only post-doc looking for a high-powered lab to jumpstart your research career. Whose lab would you really want to work in?

On the one hand you have David Livingston, Irving Weissman, and Paul Nurse. On the other hand you have Eli Glatstein, Gillies McKenna, Dennis Hallahan, Ralph Weichselbaum, some of the better known research-oriented Radiation Oncologists but clearly not in the same league as the other group. Albert Koong??? Are you kidding me?

 

[Doctor&Geek]

Hey, lets give these young guys a break. It's hard enough for physician scientists in general to succeed especially when the only opportunities that arise are at best half-solutions. Besides, people who you might say have "mediocre" research exist in all departments, not just radonc.

EDIT: If you were just starting out - it would be unfair to compare yourself to Weinberg and Sharp, no?

 

[Ursus Martimus]

I'd like to point out that of your list, only Dr. Fuks is a practicing radiation oncologist and has a lab. (Actually, I'm not sure about Dr. Kolesnik). I hope to see more people like Albert Koong,

First off , Fuks is no longer on the map. He was indited in the same insider stock trading SNAFU that sent Martha Stewart to the big house. I would suggest that he is not a model.

Both Koong and and another faculty member at Stanford Quynh-Thu Le, M.D. are up and coming and I would agree that you have to be fair as they are relatively young.

The gang at the U of Chicago are often heralded as basic science leaders. Show me their pubs.

One name that has escaped the list, who I think is a good example, is Paul Harari at University of Wisconsin.

 

[Doctor&Geek]

I'm not quite sure what's going on - Fuks published an ATM/ATR paper in Nature Cell Biology after the Imclone scandal blew over. Eh, whatever. (EDIT: actually Nature Medicine)

 

[trublu]

Well, again, by that rationale, chairs of medicine and pediatrics departments wouldn't be supporting translational scientists, let alone basic scientists.

Medicine and (to a lesser degree) pediatrics have a slew of therapeutics in action today, helping patients, born out of basic and translational science. This sort of "efficacy data" provides the incentive to support the research that has proven beneficial to the patient.

Radiation oncology is missing that incentive.

Right?

 

[radonculous]

I can't believe that I'm actually taking time out of my work day to write this, but I feel all this negativity toward the bench science of radiation oncologists exhibited by RadOncMan needs more rebuttal. (Though it's good to see him not writing in all caps anymore). Especially because of the popularity of this website as a source of information about the field by prospective medical students.

First of all, clicking on the Glazer link and his pubs is pretty impressive. He looks like he's in his 40's, and 70 publications including Science is nothing to scoff at. I don't know if anyone is claiming for this guy to be the best Radiation Oncology has to offer, but as an example of how prolific and successful one can be in the field while doing research.

Secondly, it seems to me that if you're a PhD only post-doc looking for a "high-powered lab" to jumpstart your career, you don't just choose labs for reputation - you choose them because they are doing work you're interested *now* - not past glories. I leave this open for comment from people who actually have PhD's.

Thirdly, this whole name dropping / who's the best / pissing contest between disciplines (and programs) is stupid. For prospective students, it's important to go to a respected program but also just as important to make a name for themselves. If you're not at the most academically inclined program but you write enough papers and participate enthusiastically in research, I'm sure you could find an academic job somewhere, and if you continue good research and are not a big jerk, then you could carve yourself out a nice academic practice.

But really, who cares what *we* think the big names are? Who cares what labs *we* think are the best or not the best. For all we know, I could be a plumber in Milwaukee and RadOncMan could be 10 year old kid named Spanky with a AOL account and a medical dictionary. All that matters is if a program is a good fit for the prospective student or not, and that fit is a dialogue that occurs between the student and the program, without the input of websites, scuttlebutt, rumors, your great uncle Frank's barber's cousin the medical oncology nurse, and that greasy weaselly guy who sat in front of you the 1st year of medschool and really wanted to become either a pathologist or a dermatologist or a radiation oncologist or an opthalmologist depending on "lifestyle". The dialogue certainly doesn't include idiot blabbering posters (of which I have become one). I shudder to think of prospective students thinking less about the field of radiation oncology or thinking to themselves, "hmm.. not much basic science in radiation oncology.." just because they've been reading this thread. All across the country, in all the major academic center radiation oncology departments there is major, important, substantive research being done by radiation oncologists. And frankly it is insulting to hear people bad-mouth these good people with inane remarks and analysis.

And Radoncman, if you only "really respect" one guy's research, well, there's nothing more that can be said is there? I've never met Albert Koong, but I'm glad he's working at a bench somewhere doing cancer research instead of posting obnoxious opinions about people's work and opinions about the field in general. Spanky, get off the internet. Your big sister needs to use the phone.

From what I know Kolesnick is a research only guy... and not even a Radiation Oncologist. He's probably the only guy mentioned here whose work I really respect.

Look at it this way. Pretend you are a PhD only post-doc looking for a high-powered lab to jumpstart your research career. Whose lab would you really want to work in?

On the one hand you have David Livingston, Irving Weissman, and Paul Nurse. On the other hand you have Eli Glatstein, Gillies McKenna, Dennis Hallahan, Ralph Weichselbaum, some of the better known research-oriented Radiation Oncologists but clearly not in the same league as the other group. Albert Koong??? Are you kidding me?

 

[Gfunk6]

Wow.

This thread has really evolved beyond the scope of the original poster's main question. In short, it was this:

does this mean that rad onc as field is not very supportive of people who want to pursue basic science?

I think the answer is a qualified no. There are people who do basic research, but only a few programs really have a model to accomodate such interests.

As to this comment,

I shudder to think of prospective students thinking less about the field of radiation oncology or thinking to themselves, "hmm.. not much basic science in radiation oncology.." just because they've been reading this thread.

I don't really view this thread (or board) as fully representative of the field of RadOnc. I think we (as posters) are cognizant of the fact that we are just a bunch of anonymous contributors. However, I do not want to stifle a meaningful discussion simply because it may alienate some people. In fact, if said individuals are silly enough to be scared away from a field simply due to anonmyous posts, I would venture they were not suited for the field anyway.

The reality is, a lot of the traditional "research powerhouses" are losing residents into private practice. Very few programs offer a good, solid academic career track.

And, in my opinion, this statement is flat out false,

If you're not at the most academically inclined program but you write enough papers and participate enthusiastically in research, I'm sure you could find an academic job somewhere, and if you continue good research and are not a big jerk, then you could carve yourself out a nice academic practice.

The problem here is what do you consider research? Anybody can slap together a few dosimetry studies and/or retrospective clinical reviews during residency. However to do serious basic or translational research is NOT something you can do if you are "not at the most academically inclined program." Also, you are in for a big surprise after residency if you try to demand 80% research/20% clinical time and a faculty poition w/o some major grant support. And, of course, six months of research during residency is simply not enough to net you grants. Exacerbating things, chairs may demand you do two MORE years of fellowship simply to get an academic position. Of course, you will be paid minimally though you have completed a full RadOnc residency.

With crappy choices like these, it is not surprising so many are going into private practice.

This field demands research from its applicants and demands that we say we are going into academics. Yet, it often fails to provide those very opportunities for its residents. This is definitely a problem that needs to be exposed and addressed.

 

[RadOncMan]

I second the comments of Gfunk, which is that I don't believe there is a lot of support out there for basic science Radiation Oncologists.

I think a lot of my comments are being misconstrued by Radonculous. My point in comparing comparing other physician scientists in other disciplines is to point out the disparity in quality of basic science research in a field such as Medical Oncology versus Radiation Oncology. This isn't to say that there isn't quality basic science work done in Radiation Oncology, only that it is not at the same level as Medical Oncology and one has to wonder why. When I spoke with many of the Chairman on the interview trail, I just didn't get the impression that a lot were going to commit research time for their junior faculty. Dr. Le - at Stanford - who now does 50:50 research vs clinical work once told me that if you really wanted to make an impact in research you should try and get a Chairman to give you 80:20 time. I think it's a shame that someone like her who is bright and has a lot of potential for contribution in research may be limited because of time constraints. And 50:50 often turns out to be 40:60 or even 30:70 because when it comes down to it, patients will always inevitably come first.

Albert Koong - I happen to know him. Nice guy. No disrespect to the guy at al and surely he has the potential to do some nice work for the field. However, I wouldn't necessarily single him out above many other up and coming physician scientists in the field.

Not trying to scare anyone out of the field, and seriously it's only one guy's opinion. I do think that it is more difficult to do basic science research in the field and I believe there is quite a bit of evidence to validate that point. The field may change though - I don' think there is any other field that has a higher percentage of MD/PhD's now. And when you have some programs which target only MD/PhDs, you know the focus on research must be changing - at least at some places.

 

[radiaterMike]

I'd have to agree with radonculous. There seems to be a lot of derogatory comments about well accomplished clinician scientists in Radiation Oncology. I doubt that any of the posters here have accomplished nearly as much.

Radiation Oncology was changed from a 4 year residency to a 5 year residency in order to allow programs to incoporate protected research time. Not all programs have taken advantage of this, but enough have done so to accomodate applicants who have a genuine interest in research.

 

[CNphair]

I do think that it is more difficult to do basic science research in the field and I believe there is quite a bit of evidence to validate that point.

I am sure you guys all know what you are talking about...I just find the current situation perplexing. On the interview trail, it often feels like no one wants to talk about anything BUT basic science research. And, God forbid, you come out and say you are really not interested. The reaction at some of the top programs is icy at best. So are programs just trying to put on airs about training physician scientists? If you look at recent graduates, it would certainly seem so...Or are they just optimistic that they can change the field?

 

[Thaiger75]

I am sure you guys all know what you are talking about...I just find the current situation perplexing. On the interview trail, it often feels like no one wants to talk about anything BUT basic science research. And, God forbid, you come out and say you are really not interested. The reaction at some of the top programs is icy at best. So are programs just trying to put on airs about training physician scientists? If you look at recent graduates, it would certainly seem so...Or are they just optimistic that they can change the field?

No, I don't think that programs are grooming people to become physician scientists. I mean there are certainly top programs that prefer people with those interests (ie U Chicago), but I think the general feeling towards people who are interested in basic science/translational research is a favorable one, not necessarily over pure clinical academicians. As much as clinical research will help improve oncology, the future lies in the molecular biology of cancer and ways to crack open its secrets. If that's the future, then it only seems natural to find people who can lead in that area.

 

[RadioactiveMan]

You have to understand that the future of the field is in radiobiologic modifiers. New technology in the form of IMRT, protons, stereotactic radiosurgery, etc. will only advance the field one step further. After that, it's basic research. Most academic centers realize this. Hence, the emphasis on basic research. The problem is that most programs also realize that applicants are lying/misleading them about their interest in basic research and their intention on entering academics. They're forced to take as many as they can knowing that only a small percentage will ever actually go on to careers that will advance the field.

 

[Michael Spiker]

I am sure there are many more who are radiation oncologiests and well-accomplished basic-science researchers, but one comes to my mind is Mark Groudine at the University of Washington.

He is the director of basic science research at the Fred Hutchinson Cancer Center, a member of the National Academy of Sciences, and most certainly a top-notch scientist.

I think the emphasis on basic science has been less in rad onc than in med onc, but that's quickly changing. Look at the number of MD-PhD's going into the field. One could argue rad onc is even more amenable to bench research than heme-onc is, since the clinical burden is less. And Rad-onc is much less saturated than heme-onc with "physician-scientists".

If you are interested in science, rad onc would be a great choice.

 

[deleted4401]

I'm on the same page as CNPhair, not knowing enough about this stuff, but I totally agree with her.

If the case is that basic science research is weaker than, say med-onc or ped-onc, I can't understand the emphasis during the interview process. Last year, I was berated at USC by the physicist because I didn't have an answer to "If you had unlimited funding, what type of a basic lab would you have?" Although, in my head, I was thinking it would be a very nice one with plasma screen TVs and leather couches and very fancy test tubes and chromed-out bunsen burners ... besides the point.

After last year's un-Match, I was told by many program directors to spend a year or two in the lab. And again, this year I'm asked about that stuff, and I don't think more than a few of the programs offer more than 3-6 months for research. Some let you extend to a year, if you are successful in the first six months, but that was the exception rather than the rule.

I did have an interesting conversation with one attending, because I have an interest in medical education/curriculum development/outcome vs. process based learning ... the way it is set-up allows for flexibility based on students' personal preferences and learning styles, but we agreed that very few programs want to use the time effectively.

One program that I feel should be a model for the modern curriculum, essentially gives you 1 year to do whatever you want - lab research, clinical research, outside electives (i.e. go to Seattle or Memphis to round out your training), one person is doing an MBA while doing research. They told me as long as I had a reason for it, I could do it.

Another thought: maybe this lack of flexibility is because in the past, board pass rates were quite low. Currently, I almost always hear 100% pass rates for the last few years for almost every program. Now that we have the top medical students in the country, they program directors may start offering more flexibility in the curriculums.

Final thought: maybe some people (i.e. me) don't know if they have a talent, aptitude, or interest in basic science research. If you only get 3 months, how would you ever find out?

-S

 

[eidolon]

Wow . . . I had no idea that this thread would generate so much positive energy!

However, if someone could kindly respond to one of my questions, it would be much appreciated--are people trained under the Holman pathway at a disadvantage when looking for jobs since there seems to be a general perception (except at very few institutions) that these individuals may be less competent clinically than their counterparts who went through the standard training process? What is really perplexing is that how did the Holman pathway ever come into existence since so many instituations appear to do only lip service to this mode of training!

As an afterthought, one of the reasons I believe why it has been difficult to produce the same quality of research in rad onc compared to other fields is that radiation oncologists tend to focus on very "practical" questions that have direct implication for treatment, i.e. radiosensitizers. On the other hand, medical oncology and other fields tend to ask broader questions regarding mechanisms and disease processes. The latter is much more time consuming and require more upfront commitment from a department or institution in terms of funding. However, those kind of projects are more likely to have a wider impact when they do yield a positive result. Unfortunately radiation oncology has been such an economically lucrative field that most departments would rather dedicate the resources to patient care that may generate more revenue overall?!?!

 

[Gfunk6]

are people trained under the Holman pathway at a disadvantage when looking for jobs since there seems to be a general perception (except at very few institutions) that these individuals may be less competent clinically than their counterparts who went through the standard training process? What is really perplexing is that how did the Holman pathway ever come into existence since so many instituations appear to do only lip service to this mode of training!

There is no question that people who are trained to conduct bench research as well as see oncology patients have to appease faculty in both groups when seeking a position. At my own institution, I have seen junior faculty candidates with outstanding research credentials be turned away b/c the attendings felt that they would not interact very well with patients.

However, in regards to the Holman Pathway in particular . . .

1. The # and types of cases you need to do to satisify the ABR clinical requirments does change a little. However, at virtually all programs I visited, the PD/residents claimed that they all greatly exceeded the minimum number of cases in 36 months of clinical work. Therefore Holman candidates should not have a big problem meeting the requirements in 27 months (one full day clinic/week during your research). From the ABR Website: "For adult external beam cases, it is expected that Holman Pathway residents will simulate a minimum of 350 cases over their 27 months of clinical training instead of 450 cases during a minimum of 36 months of standard clinical training."

2. The ABR changed Holman so you now apply at the start of your PGY-2 year. However, it states very clearly that residents must be performing very well clinically in order to undertake this pathway. In other words, if (in the opinion of the PD) your clinical skills are lacking, you are not supposed to enter Holman.

3. Ultimately, you have to still take the Bio/Phys written boards and the Clinical oral boards. These will be graded on percentiles, giving your potential employers another yardstick with which to measure your clinical acumen.

So while Holman pathway particpants have, on the whole, had less clinical time than their counterparts I don't think it would be accurate to label them as "less competent."

As to your 2nd question, remember that Holman is purely optional and program-dependent. You can't do it unless the PD and Chair are on board. As it merely presents another option for candidates who are capable of doing it, it is not really an issue at clinically-oriented programs. These programs would/could not do Holman anyway, but why would they stand in the way of granting the option to other research-oriented schools?

 

[G'ville Nole]

With all of the almost militant longing for radiation oncologists to abandon the clinics en masse and take up permanent residence in the wet labs upstairs, I thought I'd just throw a little cold water on everyone...

If basic science is your raison d'etre , and the bench calls to you like a siren, why on earth would you go through four years of med school, and all of the attendant hierarchy, hazing and debt to achieve your aim? Add to that the neurosis (and, yes, the politics) of an extremely competitive match process. You put yourself through all of this, when simply obtaining a PhD in your desired field of study is not only less stressful, but more focused on the actual task of advancing that given field, without bothersome distractions like OB-GYN call or actual patients.

I acknowledge that there are folks who started down this path with a basic science slant (e.g. MSTP), and some who gained an appreciation for basic science once they started med school. Maybe RadOnc Man et al. are cut from this cloth, and we can look forward to great and profound leaps forward in our understanding of the fundamental questions of cancer biology because of their outstanding work and perseverance in the lab.

I can only speak to my own motivations. I've spent time behind a wet bench, and don't particularly like it. I DO like taking care of cancer patients, and I feel like I'm pretty good at it. I've pursued research interests that will never get me published in cell, but may help the way we deliver treatments to people. I also like spending time with my wife and kid. There, I said it; y'all can offically call me out as a dilletante and slacker.

As Judge Smails told Danny Noonan in Caddyshack "Well, the world needs ditch-diggers, too." You guys go cure cancer; God bless you and more power to you. I'll be here in the ditch if you need me.

 

[CNphair]

I was berated at USC by the physicist because I didn't have an answer to "If you had unlimited funding, what type of a basic lab would you have?" Although, in my head, I was thinking it would be a very nice one with plasma screen TVs and leather couches and very fancy test tubes and chromed-out bunsen burners ... besides the point.


-S

Ok, this made me laugh. I would have thought the same...only added some couture accessories.

 

[Gfunk6]

You guys go cure cancer; God bless you and more power to you. I'll be here in the ditch if you need me.

Thanks for the kudos!

However, it IS possible to have love of caring for cancer patients as well as bench research. They need not be mutually exclusive.

If basic science is your raison d'etre , and the bench calls to you like a siren, why on earth would you go through four years of med school, and all of the attendant hierarchy, hazing and debt to achieve your aim?

I've pursued research interests that will never get me published in cell, but may help the way we deliver treatments to people.

Such opinions are quite common in the medical profession. All I can say is that we do what we enjoy. My career would not be fulfilled without both patient contact and my beloved micropipetters.

The whole MSTP philosophy is to train physicians who are also trained in laboratory investigation of human diseases. I could say the same thing to you: My research may never be published in Cell, but it may improve patient care.

True I may never be pulling in $750,000 as a full partner, have a financial share in the linear accelerators I treat patients with, nor impress the neighbors in my pimped-out BMW, but we all strive for job satisifaction in our own way, right?

 

[G'ville Nole]

Thanks for the kudos!

Such opinions are quite common in the medical profession. All I can say is that we do what we enjoy. My career would not be fulfilled without both patient contact and my beloved micropipetters.

1) Your welcome

2) An excellent response. We DO do what we enjoy, and by god, we should! I for one am glad there is a nice balance of clinicians and basic scientists in the field. I can't think of another discipline to which non-MD doctors are so integral. The influx of MD/PhDs in recent years just means there are more MDs who can converse intelligently with the PhDs. Nature publications or no, I think that's great for the field.

To speak to the OP's initial question, think of it in terms of numbers. Radiation oncology has been, and continues to be a very small field. Not only that, but the research directions one can take once in the field are incredibly broad. It stands to reason that some of the brilliant minds in rad onc would be drawn in directions other than molecular bio. Of the portion who ARE drawn to it, an even smaller fraction would be expected to reach the lofty heights extolled in previous posts. Would the percentage be smaller as compared to med onc, maybe not, but the "n" sure as heck is. FWIW, non-MD doctors probably reach these heights a greater proportion of the time, because the lab is their sole livelihood. To quote RadOnc Man: "Anyone thinking they can spend less than 75% of their time on research and regularly publish in Nature is kidding themselves." These guys know it, and put 100% of their efforts into their work.

I'm glad they (and you, GFunk) do it, I can't. Genius requires a certain single-mindedness; I've seen some lab docs with the "thousand-yard stare" borne out of spending years of their lives barking up what turned out to be the wrong tree. I wouldn't trust myself to ask the right questions. Then again, most of the successful basic science guys I've met share one characteristic; they weren't setting out to make a great discovery, they were just intensely curious about something, and went where that curiosity led. That's really cool, but it's not something you can fake. You either have it or you don't. With the influx of physician-scientists to the field, I'm optimistic that the "role models" are forthcoming.

 

[eidolon]

With the influx of physician-scientists to the field, I'm optimistic that the "role models" are forthcoming.

Hope you're right

 

[RADio goo goo]

The fact is that there are more physician scientist types entering residency than ever before in our field, and the fact is that there really aren't that many programs out there that can support this career post residency.

This year, I can count with my fingers the number of programs that say they could support a junior physician scientist in their department, and I can count with my five fingers the number of programs that could actually support a physician scientist well - meaning adequate salary, start up funds, protected time, mentorship, environment, etc...

Many big name programs, despite what one would expect actually are unable to support a physician scientist, unless they come independently funded (K08's, R01's etc...).

Soooo... if you are sincerely interested in becoming a big time bench research person within our field, plan ahead, and develop your career during residency from day 1.

Competition will get more fierce with so many good candidates coming out in the coming years... and NIH grant funding has hit an all time low...

Please stop bashing our current physician scientist within the field.. I personally have respect for anyone in any field who has the energy and the drive to see patients, and get an R01 given the same 24 hours in a day ; Many have given up much to pursue advancement of our field - what they deserve is our respect, and encouragement;

 

[eidolon]

Many big name programs, despite what one would expect actually are unable to support a physician scientist, unless they come independently funded (K08's, R01's etc...).

can you elaborate on why this might be the case? I thought rad onc is a very academic field (and wealthy too, at least compared to the med onc colleagues). so if the med onc depts can do it, why can't rad onc? am I missing something?

 

[RadOncMan]

can you elaborate on why this might be the case? I thought rad onc is a very academic field (and wealthy too, at least compared to the med onc colleagues). so if the med onc depts can do it, why can't rad onc? am I missing something?

$$$. Less clinical time means less clinical revenue. Unless you bring in your own grants to help cover your own salary and research expenditures, the department is taking a loss in revenue for the more time you spend on research. This is particularly true at private institutions where there is no state funded support.