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Occasionally when I'm doing a Powerpoint of one sort or another I have occasion to quote Franz Buschke's 1962 paper "What is a Radiotherapist?" In my own mind I imagine it right up there with Marie Curie looking down at the radiation dermatitis on her hands circa 1900 and having the realization that what radiation was doing to the normal cells of her digits it might also do to diseased or cancerous tissue. Whether or not Buschke's paper was that auspicious, I don't know. I believe Ed Halperin likes it; it predates the formation of modern radiation oncology residencies. I wanted to quote a snippet from it (which I underlined below), but on better thought just a snippet would do a well-written, important paper a disservice. The more things change, the more they stay the same. Agita over the role of the radiation oncologist: forever our lot. The letter-within-the-paper he writes below was penned almost 70 years ago.
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Some years ago, while I was still associated with the Tumor Institute of the Swedish Hospital in Seattle, Washington, a sophomore student from one of the larger mid-western medical schools asked me: "Can you explain to me what a radiation therapist is and does? I have some idea of the function of a gynecologist or a surgeon, but none of us has a very clear notion of the place of a radiotherapist." This question has recurred more frequently in recent years; particularly since, during the last decade, the appreciation of radiation therapy as a clinical specialty has grown and thus the understanding of the radiotherapist's function in a medical community, on the staff of a hospital, and on the faculty of a medical school has become more important.
In our own department, where general radiologists and radiation therapists are trained side by side, we notice that the realization of the difference between the training and the expected functioning of a general radiologist and of a specializing radiotherapist dawns only slowly.
By chance I recently ran across a copy of a letter which I had written ten years ago in answer to a question of this kind from one of our referring Seattle physicians. This letter seems, under the present circumstances, even more pertinent than it was ten years ago, and the Editor of RADIOLOGY has encouraged me to publish it as an editorial. This letter defines the role of the radiation therapist as a clinical radiological oncologist, not as a Utopian suggestion or as the result of theorizing armchair philosophy. It rather describes in a perhaps even somewhat naive fashion what actually had been practiced during the preceding thirteen years to the satisfaction of the patients, the medical staff, the radiation therapists themselves, and even of the board of directors of the hospital.
The letter follows :
Dear Dr. L.:
You asked me the other day on the telephone a quite interesting question. You told me that one of your friends asked you, "What is this fellow Buschke actually doing… is he a radiologist, an internist, or what is he?" This question is, indeed, quite legitimate because the way we in this Institute try to practice our specialty is not orthodox according to the generally accepted subdivision of medical specialties and does not fit into any pigeonhole. This is, of course, due to the fundamental fact that neoplastic disease in all its forms cuts across the other fields of medicine and, while you may call such specialties, as urology, ophthalmology, and otolaryngology, vertical specialties, so that you can place them alongside one another, cancer therapy may be called a horizontal specialty that assumes a part of the functions of all the rest. You can, of course, say the same about cancer surgery, but then, the majority of surgeons are general surgeons and few limit their activities to the treatment of neoplastic disease, as we do with respect to radiation therapy.
Both Dr. Cantril and I have in our offices the certificate of the American Board of Radiology, which certifies that we are "qualified to practice the specialty of Radiology." Thus, we will have to call ourselves radiologists, but, interpreted in the generally accepted fashion in which radiology is practiced, this means little indeed with reference to our actual work. In addition, we have limited our field to radiation therapy and do not practice diagnosis. Thus, we are primarily concerned with radiation therapy of neoplastic diseases. But we do not consider ourselves, as too many radiologists still do, technicians who deliver radiating energy to patients under the order of the referring physician. We try to be clinicians who treat the patient. While the patient is under our care, we take full and exclusive responsibility, exactly as does the surgeon who takes care of a patient with cancer. This means that we examine the patient personally, review the microscopic material, perform gynecological examinations, take a specimen for biopsy if necessary, examine the larynx, bladder, or whatever is necessary. On the basis of this thorough, clinical investigation, we consider the plan of treatment that we suggest to the referring physician and to the patient. We reserve for ourselves the right to an independent opinion regarding diagnosis and advisable therapy, and, if necessary, the right of disagreement with the referring physician. In some instances, we may even differ with the pathologist if the integration of equivocal microscopic findings into the entire clinical picture suggests the necessity for re-interpretation and change of diagnosis. During the course of treatment, we ourselves direct any additional medication that may be necessary, such as antibiotics or sedatives, blood transfusions, etc. We are ready to be called in an emergency, such as laryngeal edema or uterine hemorrhage, at any time.
It may appear that, if this is so, the radiation therapist is a jack-of-all-trades, and it may be argued that it is impossible for one man to become really competent in all special fields and the necessary specialist technics. This is quite true, and we do not claim to be that competent. For this very reason, we feel the necessity of close co-operation with those specialists who, in turn, understand what we are doing and what we are attempting to accomplish. We will do a cystoscopy in co-operation with the urologist but, before we treat a carcinoma of the bladder, it is essential that we ourselves have a chance to see this bladder. We do not do a bronchoscopy ourselves. In many instances we request consultation with the respective specialist in the field before a decision as to surgery or radiation therapy is made or a plan of combined therapy is outlined. We will co-operate closely with the internist in the treatment of such conditions as leukemia, but we will not unreservedly folllow his orders. The necessity for such close cooperation-I may mention incidentally will perhaps also make it understandable why in certain instances we feel that, if we treat a patient, we must insist on the cooperation of a particular specialist regardless of original referral; this specialist may have cooperated with us regularly throughout the years, so that we know each other's language. This has at times led to complaints, but we have attempted to with stand this onslaught on our ''misconception of medical ethics" because we have felt that the paramount purpose is to serve the patient.
We have often been asked what is the secret of the results of our great teacher, Coutard, whose accomplishments in those fields to which he applied himself have so far never been surpassed anywhere and have been equaled in only a few places. The secret was not the much quoted "Coutard technic" it was rather his clinical approach with the radiotherapist acting as a physician and not as a technician.
It has been our good fortune to be permitted in this hospital to practice radiology during the last thirteen years in the fashion described. It is understandable that this has been baffling to some, as it has prompted your unfortunately too legitimate question. Unfortunately in many places, and even in some of the leading institutions, radiation therapy is still not practiced in this fashion, but rather as an annex to surgery, with the radiation therapist more or less acting as a technical assistant to the surgeon. Last week I happened to have a letter from Dr. George Pfahler of Philadelphia, the dean of American radiology, stressing this same point. In it he says, "As you well know, when we began practise, we were looked upon sometimes as electricians, sometimes as photographers, but even in my own office I had a patient ask me in the early days, 'Are you a real doctor?' There are still a lot of people who are not sure whether we are real doctors.'' My secretary told me recently that she over heard a talk about the Tumor Institute when the remark was made: "I suppose they are M.D.'s?"
A considerable number of our colleagues in general practice and in all specialties have become our good friends and have come to appreciate that our approach has contributed to the welfare of their patients and has not detracted from their own standing in the eyes of those whom they have referred to us for therapy or consultation.
What you want to call us, I leave to you. Admittedly we do not seem to fit into a pigeonhole, as medicine and its specialties are practiced today, but fortunately we are not the only freaks of the kind described. There are a number of institutions and individuals who interpret their calling and who practice their radiotherapeutic specialty in the same fashion regardless of the term that is stamped on them by their certificate of specialty. We believe that we are in good company.
The problem which prompts your question is closely related to some other fundamental problems in the field of cancer treatment. The difficulty in integrating radiation therapy into the field of general medicine explains in part the still un satisfactory state of cancer teaching in most medical schools. It is indeed difficult to decide who should teach cancer therapy. On the other hand, a real understanding is considerably facilitated if the subject is not exclusively discussed by the specialists (gynecologists, laryngologists, etc.) be cause certainly the physician who sees patients with cancer in its many manifestations and in large numbers will have a better understanding of the biology and pathology of neoplastic disease in all its phases and of the possibilities of therapeutic approach.
The problem also involves the much discussed question of separation of radiation therapy from x-ray diagnosis. In European countries, particularly in England, this separation has been accepted as a matter of course for many years. In this country the number of radiologists who limit themselves to radiation therapy is still extremely small. The fight against this separation is understandable on economic grounds. It is almost impossible to practice adequate radiation therapy in the fashion described, as an independent specialty, in private practice because of the high expense involved in the necessary facilities (x-ray apparatus operating at different voltages, adequate radium facilities, radioisotope facilities), and organization (follow-up service, record department, etc.). On the other hand, it should be frankly admitted that one man cannot possibly be competent in both x-ray diagnosis, which branches out into all medical specialties, and radiation therapy, which includes a fundamental knowledge in gross and microscopic pathology, of diagnostic technics for cancer in all locations (including the less complicated endoscopic procedures), judgment as to the indications for and knowledge of the pharmacology and technic of chemotherapeutic agents (nitrogen mustard, urethane, antifolics), plus a comprehensive understanding of physics, clinical indications for, and technics of x-ray, radium, and isotope therapy, and the psychological management of the cancer patient.
You will now understand why I could not really answer your question on the telephone with one word. I am glad that you were frank enough to ask the question and thus give me a chance to answer it.
With kindest regards, and in appreciation of your consistent cooperation, I am,
Sincerely yours,
Franz Buschke, M.D.
-------------
Some years ago, while I was still associated with the Tumor Institute of the Swedish Hospital in Seattle, Washington, a sophomore student from one of the larger mid-western medical schools asked me: "Can you explain to me what a radiation therapist is and does? I have some idea of the function of a gynecologist or a surgeon, but none of us has a very clear notion of the place of a radiotherapist." This question has recurred more frequently in recent years; particularly since, during the last decade, the appreciation of radiation therapy as a clinical specialty has grown and thus the understanding of the radiotherapist's function in a medical community, on the staff of a hospital, and on the faculty of a medical school has become more important.
In our own department, where general radiologists and radiation therapists are trained side by side, we notice that the realization of the difference between the training and the expected functioning of a general radiologist and of a specializing radiotherapist dawns only slowly.
By chance I recently ran across a copy of a letter which I had written ten years ago in answer to a question of this kind from one of our referring Seattle physicians. This letter seems, under the present circumstances, even more pertinent than it was ten years ago, and the Editor of RADIOLOGY has encouraged me to publish it as an editorial. This letter defines the role of the radiation therapist as a clinical radiological oncologist, not as a Utopian suggestion or as the result of theorizing armchair philosophy. It rather describes in a perhaps even somewhat naive fashion what actually had been practiced during the preceding thirteen years to the satisfaction of the patients, the medical staff, the radiation therapists themselves, and even of the board of directors of the hospital.
The letter follows :
Dear Dr. L.:
You asked me the other day on the telephone a quite interesting question. You told me that one of your friends asked you, "What is this fellow Buschke actually doing… is he a radiologist, an internist, or what is he?" This question is, indeed, quite legitimate because the way we in this Institute try to practice our specialty is not orthodox according to the generally accepted subdivision of medical specialties and does not fit into any pigeonhole. This is, of course, due to the fundamental fact that neoplastic disease in all its forms cuts across the other fields of medicine and, while you may call such specialties, as urology, ophthalmology, and otolaryngology, vertical specialties, so that you can place them alongside one another, cancer therapy may be called a horizontal specialty that assumes a part of the functions of all the rest. You can, of course, say the same about cancer surgery, but then, the majority of surgeons are general surgeons and few limit their activities to the treatment of neoplastic disease, as we do with respect to radiation therapy.
Both Dr. Cantril and I have in our offices the certificate of the American Board of Radiology, which certifies that we are "qualified to practice the specialty of Radiology." Thus, we will have to call ourselves radiologists, but, interpreted in the generally accepted fashion in which radiology is practiced, this means little indeed with reference to our actual work. In addition, we have limited our field to radiation therapy and do not practice diagnosis. Thus, we are primarily concerned with radiation therapy of neoplastic diseases. But we do not consider ourselves, as too many radiologists still do, technicians who deliver radiating energy to patients under the order of the referring physician. We try to be clinicians who treat the patient. While the patient is under our care, we take full and exclusive responsibility, exactly as does the surgeon who takes care of a patient with cancer. This means that we examine the patient personally, review the microscopic material, perform gynecological examinations, take a specimen for biopsy if necessary, examine the larynx, bladder, or whatever is necessary. On the basis of this thorough, clinical investigation, we consider the plan of treatment that we suggest to the referring physician and to the patient. We reserve for ourselves the right to an independent opinion regarding diagnosis and advisable therapy, and, if necessary, the right of disagreement with the referring physician. In some instances, we may even differ with the pathologist if the integration of equivocal microscopic findings into the entire clinical picture suggests the necessity for re-interpretation and change of diagnosis. During the course of treatment, we ourselves direct any additional medication that may be necessary, such as antibiotics or sedatives, blood transfusions, etc. We are ready to be called in an emergency, such as laryngeal edema or uterine hemorrhage, at any time.
It may appear that, if this is so, the radiation therapist is a jack-of-all-trades, and it may be argued that it is impossible for one man to become really competent in all special fields and the necessary specialist technics. This is quite true, and we do not claim to be that competent. For this very reason, we feel the necessity of close co-operation with those specialists who, in turn, understand what we are doing and what we are attempting to accomplish. We will do a cystoscopy in co-operation with the urologist but, before we treat a carcinoma of the bladder, it is essential that we ourselves have a chance to see this bladder. We do not do a bronchoscopy ourselves. In many instances we request consultation with the respective specialist in the field before a decision as to surgery or radiation therapy is made or a plan of combined therapy is outlined. We will co-operate closely with the internist in the treatment of such conditions as leukemia, but we will not unreservedly folllow his orders. The necessity for such close cooperation-I may mention incidentally will perhaps also make it understandable why in certain instances we feel that, if we treat a patient, we must insist on the cooperation of a particular specialist regardless of original referral; this specialist may have cooperated with us regularly throughout the years, so that we know each other's language. This has at times led to complaints, but we have attempted to with stand this onslaught on our ''misconception of medical ethics" because we have felt that the paramount purpose is to serve the patient.
We have often been asked what is the secret of the results of our great teacher, Coutard, whose accomplishments in those fields to which he applied himself have so far never been surpassed anywhere and have been equaled in only a few places. The secret was not the much quoted "Coutard technic" it was rather his clinical approach with the radiotherapist acting as a physician and not as a technician.
It has been our good fortune to be permitted in this hospital to practice radiology during the last thirteen years in the fashion described. It is understandable that this has been baffling to some, as it has prompted your unfortunately too legitimate question. Unfortunately in many places, and even in some of the leading institutions, radiation therapy is still not practiced in this fashion, but rather as an annex to surgery, with the radiation therapist more or less acting as a technical assistant to the surgeon. Last week I happened to have a letter from Dr. George Pfahler of Philadelphia, the dean of American radiology, stressing this same point. In it he says, "As you well know, when we began practise, we were looked upon sometimes as electricians, sometimes as photographers, but even in my own office I had a patient ask me in the early days, 'Are you a real doctor?' There are still a lot of people who are not sure whether we are real doctors.'' My secretary told me recently that she over heard a talk about the Tumor Institute when the remark was made: "I suppose they are M.D.'s?"
A considerable number of our colleagues in general practice and in all specialties have become our good friends and have come to appreciate that our approach has contributed to the welfare of their patients and has not detracted from their own standing in the eyes of those whom they have referred to us for therapy or consultation.
What you want to call us, I leave to you. Admittedly we do not seem to fit into a pigeonhole, as medicine and its specialties are practiced today, but fortunately we are not the only freaks of the kind described. There are a number of institutions and individuals who interpret their calling and who practice their radiotherapeutic specialty in the same fashion regardless of the term that is stamped on them by their certificate of specialty. We believe that we are in good company.
The problem which prompts your question is closely related to some other fundamental problems in the field of cancer treatment. The difficulty in integrating radiation therapy into the field of general medicine explains in part the still un satisfactory state of cancer teaching in most medical schools. It is indeed difficult to decide who should teach cancer therapy. On the other hand, a real understanding is considerably facilitated if the subject is not exclusively discussed by the specialists (gynecologists, laryngologists, etc.) be cause certainly the physician who sees patients with cancer in its many manifestations and in large numbers will have a better understanding of the biology and pathology of neoplastic disease in all its phases and of the possibilities of therapeutic approach.
The problem also involves the much discussed question of separation of radiation therapy from x-ray diagnosis. In European countries, particularly in England, this separation has been accepted as a matter of course for many years. In this country the number of radiologists who limit themselves to radiation therapy is still extremely small. The fight against this separation is understandable on economic grounds. It is almost impossible to practice adequate radiation therapy in the fashion described, as an independent specialty, in private practice because of the high expense involved in the necessary facilities (x-ray apparatus operating at different voltages, adequate radium facilities, radioisotope facilities), and organization (follow-up service, record department, etc.). On the other hand, it should be frankly admitted that one man cannot possibly be competent in both x-ray diagnosis, which branches out into all medical specialties, and radiation therapy, which includes a fundamental knowledge in gross and microscopic pathology, of diagnostic technics for cancer in all locations (including the less complicated endoscopic procedures), judgment as to the indications for and knowledge of the pharmacology and technic of chemotherapeutic agents (nitrogen mustard, urethane, antifolics), plus a comprehensive understanding of physics, clinical indications for, and technics of x-ray, radium, and isotope therapy, and the psychological management of the cancer patient.
You will now understand why I could not really answer your question on the telephone with one word. I am glad that you were frank enough to ask the question and thus give me a chance to answer it.
With kindest regards, and in appreciation of your consistent cooperation, I am,
Sincerely yours,
Franz Buschke, M.D.
