UTSW Residency Manual

MISSION STATEMENT OF THE DEPARTMENT OF RADIATION ONCOLOGY
To provide the highest quality radiation treatment to complement other cancer specialties in a multidisciplinary cancer care setting, and to provide excellence in educating physicians, scientists and therapists in clinical and research endeavors in radiation oncology.

MISSION STATEMENT OF THE RADIATION ONCOLOGY RESIDENCY PROGRAM
The purpose of the training program in radiation oncology is to provide quality education in oncology and the use of radiation in the treatment of disease.

The University of Texas Southwestern Medical Center in Dallas has been in existence since 1943. It currently consists of the UT Southwestern Medical School, the UT Southwestern Graduate School and Allied Health Sciences School. UT Southwestern Medical Center has affiliation agreements with the teaching hospitals of Parkland Memorial Hospital, Zale Lipshy University Hospital, St. Paul University Hospital and Children’s Medical Center of Dallas. Radiation oncology services had been available for both inpatients and outpatients at those hospitals and the greater Dallas area at offices in Parkland and St. Paul until September 2003. On September 2, 2003, the Moncrief Radiation Oncology Center (Moncrief ROC) began operation, and the facilities at Parkland and St. Paul were closed. The Moncrief ROC continues to provide services for the UT Southwestern medical facilities, and maintains a working relationship with the Dallas Veterans Administration Hospital.

Pediatric patients with brain and spinal cord tumors are treated with the CyberKnife stereotactic radiosurgery system at Zale Lipshy University Hospital. Pediatric radiation oncology patients with malignancies at other sites have in the past been referred to radiation oncologists at private, outside facilities. With the opening of the Moncrief ROC, and the recruitment of a radiation oncologist with a special interest in pediatric oncology, we are now treating patients from Children’s Medical Center of Dallas.

The majority of the clinical rotations offered in the residency will be at the Moncrief Radiation Oncology Center on the UT Southwestern campus in Dallas. The North Campus, which houses the Moncrief ROC and the Simmons Cancer Center, is connected to St. Paul University Hospital and the South Campus by a shuttle bus. The South Campus is the site of the main Medical Library, the UT Southwestern Medical School, and Parkland Memorial Hospital, Zale Lipshy University Hospital and Children’s Medical Center.

The major objective of the Radiation Oncology Residency Training Program is to train highly skilled radiation oncologists who are familiar with the most advanced techniques in clinical treatment and who understand the principles of cancer therapy. In addition to excellent clinical training, our goal is to provide residents with a meaningful research experience. Residents will be proficient in each of the subspecialties within Radiation Oncology, and will obtain the ability to plan complex treatments including stereotactic radiosurgery and brachytherapy. Residents will be proficient in radiation biology and radiation physics concepts to allow for board certification. The overall educational goal of the Radiation Oncology Residency Training Program at the University of Texas Southwestern Medical School is to graduate residents prepared to fill leadership positions in the field of radiation oncology in future years. In this regard, residents will conduct research in clinical, biological and physical sciences. Research will result in presentations at national meetings, publications and competition for funding from societies and foundations.

Clinical Radiation Oncology • The objective of the Clinical Radiation Oncology rotation is to teach the most advanced techniques in clinical treatment and the principles of cancer therapy in each of the subspecialties within Radiation Oncology. By the completion of the residency, the residents will be able to:

Perform histories and physicals, and diagnostic evaluations and staging appropriate to specific malignancies.
Prescribe and implement radiation therapy specific to a particular tumor site and histology, utilizing external beam irradiation, including intensity modulated radiation therapy and stereotactic radiosurgery, or brachytherapy.
Be aware of other treatment modalities available for treatment of specific malignancies, and know how to integrate combined-modality therapies.
Develop communication skills required to establish working relationships with medical and surgical oncologists, and other health-care professionals.
Achieve the core competencies as specified by the ACGME.

Medical Oncology (Adult and Pediatric) • Residents will assist adult and pediatric medical oncologists in the care of patients in the hospital and in outpatient clinics. At the completion of the rotation, they will be able to:

Radiation Physics • The objective of the Radiation Physics rotation is to teach basic principles of radiation physics, basic methods of external beam dosimetry, interstitial and intracavitary dosimetry, and principles and practices of intensity modulated radiation therapy; and to provide outstanding clinical physics training for our residents for safe, effective, and efficient delivery of radiation treatments.

Radiation Biology • The radiation biology course will provide instruction in the interaction of radiation with normal and malignant tissues, early and late effects of radiation, various types of radiation used for therapy, and training in radiation safety. Residents will be able to apply this knowledge in the selection of safe and effective treatments for patients, and will also be prepared for the board certification examination in Radiation Oncology. Residents may also spend elective time in radiation biology research.

Multidisciplinary Conferences & Tumor Boards • Residents will attend multidisciplinary conferences, and present cases as needed. They will attain the skills and experience to:

Clinical Lectures • Lectures will be provided to supplement teaching in the various rotations within radiation oncology. The goal of these lectures is to provide specific information on various disease processes and treatment options, as well as to provide a forum for discussion.

Electives • Residents may spend elective time in clinical or research rotations. Residents may elect to concentrate more heavily in one of the areas of disease already covered in the mandatory rotations, or to spend the time at a facility offering a modality not available at UT Southwestern. In either case, the goals of the rotation would be the same as the goals for the mandatory clinical rotations noted previously. Residents may also elect to perform basic research in radiation physics or radiation biology, with the goal of gaining specific training, which will form the basis of a research career.

Competency Requirements for All Clinical Rotations • On all clinical rotations, the resident is expected to demonstrate competence in six main areas as specified by the ACGME: patient care, medical knowledge, practice based learning, interpersonal skills (including communication), professionalism, and systems based practice. Additional learning objectives for each individual clinical rotation are noted below.

Required Rotations in the Radiation Oncology Department • Residents rotate through each attending physician’s service at MROC for a period of time, usually three months. During this time, the resident is expected to learn the presentation, work-up, and treatment for the malignancies covered by the attending physician.
Residents are expected to learn the following topics during each rotation:

1.  Epidemiology and etiology
2.  Presentation and natural history, including prognostic factors, patterns of spread and relapse
3. Anatomy
4. Pathology & implications of histologic subtype
5. Staging workup
6. Staging systems
7.  Prognostic factors
8.  Treatment options (surgery, radiation therapy, chemotherapy)
9.  Indication for, and types of, systemic therapy
10.  Roles for radiation therapy in malignancies of each site
11.  Radiation doses, fractionation, and techniques for various clinical settings
12.  Radiation complications; incidence, presentation, treatment

Accreditation •The UT Southwestern Residency in Radiation Oncology is accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Resident Responsibility Regarding Registration for the Radiation Oncology Board Examination • The Board Examination for radiation oncology is given each year by the American Board of Radiology. The dates of the written and oral examination change frequently. Registering for the Board Examination is the responsibility of the resident.

Selection of Residents • All residents selected for PGY-2 positions for 2009 and beyond will be selected through the National Resident Matching Program (NRMP), “the Match”.

Supervision of Residents • All clinical patient care activities by resident physicians are conducted under the direct supervision and with the full participation of the attending faculty physician. Patient assignment or referrals are to the attending physician, who maintains primary clinical responsibility. This includes new patient evaluation, re-evaluation of former patients returning with new problems, and the follow up evaluation of treated patients. Supervision of the residents’ clinical activities on a day-by-day basis is done by the attending physicians to whom they are assigned. When patient treatment involves technical or operative procedures, the attending physician supervises and participates fully in the procedures. All necessary and appropriate documentation is reviewed and verified by the attending physician.

Clinical activities of the residents outside of the assigned clinical rotations will be supervised by an attending physician. This primarily includes follow-up clinics where resident physicians assist in the post-treatment evaluation of patients to further develop skills of patient assessment, evaluation of treatment response, detection of complication and side effects, and the detection and the management of recurrent disease.

When an attending physician is designated to assume responsibility for another physicians’ clinical service, the resident physician then reports to the designated attending physician for all activities, clinical or otherwise, that would normally require supervision by an attending physician. If any resident physician encounters a situation where the designated attending physician in not immediately available, the resident should notify the Residency Program Director or Medical Director.

Resident Responsibilities • All patient care activities of the resident will be under the supervision of the attending. The resident will be responsible for:

Initial evaluation, physical examination and clinical assessment of new patients, and dictation of the history and physical
Development of a clinical treatment plan
Ordering diagnostic studies and consultations
Discussion of the planned treatment with the patient and obtaining informed consent
Simulation of treatment under fluoroscopic or CT guidance; plan verification on the fluoroscopic unit or treatment machine if appropriate
Working with dosimetry and physics to designate target volumes and critical normal tissues; designing treatment portals; specifying a treatment prescription
Monitoring of patient progress during treatment
Arranging follow-up and dictating the treatment summary

Resident Responsibilities based on PGY year • The range of resident responsibilities is the same for each PGY year, with faculty supervision regardless of year of training. However, as residents advance through the program, it is expected that the number of tasks which will need to be taught will decrease, such that by the completion of training, the resident is competent to practice radiation oncology without supervision.

Evaluation, Probation, and Termination of Residents • The residents must meet the following standards to complete the program.

At the end of each clinical rotation the appropriate faculty member evaluates the resident’s performance. A 360-degree resident performance evaluation will also be performed by a member of the nursing team, a radiation therapist and a dosimetrist. Resident evaluations are recorded using standardized questionnaires.

For each rotation, the resident will be given an overall evaluation of Unsatisfactory, Satisfactory or Exceeds Expectations. The resident is expected to address any areas that receive an unsatisfactory evaluation during subsequent rotations.

Evaluation results will be communicated to the resident by the residency program director or his/her designee. The resident will be required to review and sign a copy of the resident evaluation questionnaire within one week of being informed of their evaluation. A copy of the evaluation will be added to the resident’s file.
A written in-service examination will be given each year. Results of the examination will be reviewed with the resident. If the performance is not satisfactory, the resident may be placed on probation.
Once during each academic program year, an oral in-service examination is given to each resident. It will cover all the clinical areas, radiobiology and radiation physics. The grading scale is the same as above. It is necessary to pass this exam to progress to the next level of residency. If a resident does not pass the oral exam, he or she is placed on probation and asked to repeat the exam in 4-6 months.
Each year didactic radiation physics and radiation biology courses are given. These will require homework and formal examinations as specified by the physicist/radiation biologist in charge of the course. The resident must pass both courses to be promoted to the next level of residency. Failure to pass either course will place the resident on probation.
Probation is a very serious warning that the performance of a resident does not meet the standards set by the faculty of the Department of Radiation Oncology. At the subsequent six-month evaluation, a resident on probation will be required to demonstrate considerable improvement to remain in the residency. If the resident continues to fail the oral exam, the clinical skills assessment, the radiation biology course, or the radiation physics course, the faculty will meet to determine the disposition of the resident. The resident may be placed on a further specified probation period, with restricted privileges regarding elective time and evaluation frequency, may repeat a year, or may be terminated. Final disposition will be agreed on by the Chairman. If the resident is terminated, the resident will be notified by the program director and will be given the right to appeal as outlined in the due process policy.

Procedure for Supervision, Evaluation, Discipline, and Grievances • It is the policy of the Radiation Oncology Residency Program to supervise residents and fellows in a manner consistent with the goals of our program, the UT Southwestern Medical Center and the ACGME. These policies are stated in the UT Southwestern Medical Center Policies and Procedures for Supervision, Evaluation, Discipline, and Grievances of Graduate Medical Education Trainees, which may be viewed on the UT Southwestern Medical Center website.

Impaired physician and substance abuse policy • Possession or use of illegal substances on the UT Southwestern premises is prohibited. Standards of conduct are outlined in the UT Southwestern Handbook of Operating Procedures.

Residents will follow the policies and procedures as specified by the Department of Radiation Oncology, the University of Texas Southwestern Medical Center and affiliated institutions and where applicable Parkland Medical Center.

Beepers • All residents in the Department of Radiation Oncology are issued beepers at the beginning of their residency. The resident is responsible for ensuring that the beeper is functional, has a charged battery, and is on during duty hours. If there is a problem with the beeper, contact Sandra Durr or her designee. If there is a change in the beeper number, it is imperative that the hospital paging operator and the department be informed.

Case Logs • Each resident must maintain a log of all cases seen and treated during the residency. This is done with a web-based system administered by the ACGME. The residents are responsible for keeping an accurate log of all the patients treated and procedures performed during their residency. Rules and format for recording this information are described by the Radiation Oncology Residency Review Committee of the ACGME.

Outside Employment • Outside employment is discouraged due to the time required to adequately complete the requirements of the residency. Residents with a Physician In Training Permit are not permitted to perform medical duties outside of the boundaries of the radiation oncology training program. Any resident considering outside employment must have permission of the Program Director.

On-Call Policy • Residents will be on call for 7 consecutive days. They are required to wear beepers at all times. There is no in-house call but it is expected that the resident will respond if requested by an attending physician, physics staff, technical staff, or any other service.

For emergency on-call activities the resident will be responsible for first contact, with the assigned attending physician readily available for discussion and participation. All calls, requests, etc. must be documented by the resident physician in the form of chart notes. All cases will be discussed with the appropriate attending physician(s). Should any patient be referred for emergency consultation, the patient will be seen and evaluated expediently and the case reviewed with the attending physician(s) so that appropriate clinical management can proceed. The on-call policy is available for review on the departmental H-drive.

Resident Duty Hours • Residents are expected to be present in the department whenever patients are present in the department, each weekday that the department is open for business. The on-call resident will be available by pager 24 hours a day during the time that he/she is on-call (usually one week at a time). It is expected that residents will be in the department no more than 60 hours per week.

FRINGE BENEFITS

The following fringe benefits are currently provided to residents of the Department of Radiation Oncology, as specified in the employment agreement.

All residents commencing the radiation oncology program must have completed a clinical PGY-1 year in an accredited graduate medical education institution recognized by the ACGME.

Orientation • General orientation is conducted during the first week of the PGY-2 year (first year of radiation oncology residency).

General Comments • After orientation, the resident will be assigned to a specific faculty member. In general, this rotation will last three months. During each rotation, the resident is responsible for the care of all patients under the care of the assigned faculty member. The resident will be expected to complete a history and physical exam on each new patient. The case is then presented to the attending and the resident will make a preliminary treatment recommendation. Once approved, the resident will schedule the simulation and treatment. The resident, with faculty supervision, will perform the simulation and treatment planning, develop a final treatment plan, and supervise the patient’s treatment. The patient will be seen weekly by the resident and the attending, and will see follow-up patients scheduled for their current attending.

Chief Resident • Every resident will be chief resident for at least three months during the PGY-3 and PGY-4 years. The chief resident is responsible for representing the other residents at all staff meetings and any general meetings held by the hospital or medical school involving resident participation. The chief resident is responsible for communicating information to the other residents.

Work Schedule • The residents’ work schedule will meet the requirements of the ACGME. Duty hours will be limited to 80 hours per week, averaged over a four-week period. Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. Residents will take at-home call (pager call) on a rotation basis, and will be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.

Departmental and multidisciplinary conferences are held throughout the week. Residents must attend Radiation Oncology conferences and lectures, and the Combined Modality Conference. Residents are required to attend the multidisciplinary conference(s) attended by the faculty member to whom they are assigned.

Research Project • During their training, residents will complete an investigative project under faculty supervision. This may take the form of biological laboratory research, clinical research, medical physics research, or the retrospective analysis of data from treated patients. The results of such projects shall be suitable for publication in peer-reviewed scholarly journals or presentation at scientific meetings.

Electives • Residents may choose to spend up to 8 months on research; a minimum of 2 months must be spent on research. If they elect to not do research for the entire 8 months permitted, they may elect to spend up to 6 months on electives. Elective time may be spent at UT Southwestern, focusing on clinical areas of special interest, or at another institution, which offers experiences not available at UT Southwestern. Residents may choose elective rotations in neurologic oncology, urologic oncology, head and neck surgery, thoracic oncology, GI oncology, and gynecologic oncology as well as diagnostic imaging and surgical pathology. Elective rotations will have a duration of a minimum of one month, and are usually taken in the PGY-4 or PGY-5 years.