Pilot Study Assessing Student Interest in Combined Residency Training Pathways With Radiation Oncology

Abstract

Purpose

Most medical students have limited exposure to radiation oncology (RO) before deciding which specialty to choose for residency. This may limit the number and diversity of RO applicants. The purpose of this study was to determine students’ views on a combined pathway program of RO with internal medicine (IM), as well as other related medical specialties, as a potential means of overcoming barriers to interest in RO and the early decision point to solo training in a highly specialized field.

Methods and Materials

In July to August 2022, all 299 United States student and postgraduate year 1 members of the American Society for Radiation Oncology were sent an electronic survey assessing their views on advantages and disadvantages of a combined IM/RO training pathway, and interest in several options of combined pathway programs.

Results

Eighty participants completed the survey (response rate 27%). Thirty-four (43%) were very or extremely interested in IM/RO residency (median Likert-type rating 3, IQR 2-4). The most important potential advantages of an IM/RO pathway included greater flexibility in employment options (n = 51, 64%), enhanced general medical knowledge to facilitate ambitions in other career pathways (n = 46, 58%), improved patient care (n = 43, 54%), and having a pathway for combined hematologic/oncology and RO board certification (n = 46, 58%). In comparison to IM/RO, participants were significantly more interested in a combined RO and hematology/oncology program (median Likert-type rating 5, IQR 5-5, P = .005). Among the subgroup of 26 survey participants who believed it less likely they would apply for RO residency, 18 (69%) thought an IM/RO pathway would increase their interest in RO (median Likert-type rating 4, IQR 3-5). Interest in IM/RO did not differ by gender, race, or ethnicity.

Conclusions

Combined training pathways involving RO were viewed positively by survey respondents, and may be particularly appealing to those less committed to a career in RO. Further research will help guide recommendations for the creation of these programs.

Introduction

Historically, graduate medical education (GME) in radiation oncology (RO), was once a component of training in general radiology.^1,2 However, since 1974 therapeutic radiology (the original name for RO) split from diagnostic radiology and has had its own residency training program through the Accreditation Council for Graduate Medical Education (ACGME) and board certification process through the American Board of Radiology.^1,2 This division was rationalized by the unique and dramatically different skill set that a radiation oncologist requires, including understanding the pathophysiology and patterns of spread for all human cancers, the biology and physics of radiation delivery, the proper integration of radiation with surgical and systemic treatments, and the management of short- and long-term effects of radiation.³

RO is unique among cancer subspecialties in that students apply for it as a residency program during medical school, rather than as a fellowship program during residency, as is done for medical oncology, pediatric oncology, and all of the surgical oncologic subspecialties.³ Although some medical students may know that they want to pursue an oncologic subspecialty during medical school, it is likely that many solidify this interest through additional years of training and subspecialty rotations during their residency. In addition, RO content is not a required component of the preclinical or clinical curricula at most US medical schools, and it may be intimidating for most students to consider such a highly specialized area of medicine as RO, when their prior knowledge of it is often very limited at the time that they need to apply.⁴ Finally, not all medical schools have an associated RO department or residency program, and thus medical students might never have a reasonable opportunity to be exposed to the field.^5,6 One potential solution to this problem is to develop alternative GME pathways into RO for students who discover RO later in their education, or who may not want to sacrifice a more general medical education to pursue it. The American Board of Internal Medicine has a track record of supporting these opportunities. For instance, among 23 combined pathways, 9 include a combination with internal medicine, and 32% of all residents in a combined pathway program (n = 1857/2251) are involved in a combination with internal medicine (IM). ⁷ The largest of these programs is IM-Pediatrics (n = 1501), followed by IM-Emergency Medicine (n = 148), and IM-Psychiatry (n = 116).⁷ An important benefit of these pathways includes enabling students to pursue 2 specialties that mutually benefit their career interests in a shorter duration of training than either program alone, by mutually granting credit in 2 related disciplines.^8,9 Combining a more generalized field like IM with a highly specialized field like RO may also be perceived as valuable to students from diverse, marginalized, and/or underrepresented, backgrounds in medicine who have broader ambitions in a career trajectory that includes addressing health disparities locally or globally and/or have less awareness of RO early in medical school compared with their non UIM counterparts.¹⁰ Similarly, a combined pathway may appeal to students with career interests in diverse pathways, including administrative medicine, industry, or leadership in a cancer center or in government. However, the appeal of these potential alternative pathways in RO to students has not previously been assessed. The purpose of this pilot study was to determine students’ views on a combined pathway program between RO and IM, as well as other related medical specialties.

Methods and Materials

An electronic survey was developed by the authors of this manuscript in conjunction with the American Society for Radiation Oncology (ASTRO) using Qualtrics, a secure web application used to build and manage online surveys. The full survey is shown in Fig. E1 and included a series of questions aimed at assessing students’ demographic information, career plans, potential advantages and disadvantages of a combined IM/RO training pathway, and interest in this potential combined pathway as well as other combined pathway programs with RO and other related subspecialties. Multiple choice and 5-point Likert-type questions (ranging from 1 = not at all, and 5 = extremely) were used. The questions were developed based on available guidelines for electronic surveys,¹¹ by members of our study team, who have expertise in undergraduate and graduate medical education in radiation oncology.

The target population for the survey included those who had previously signed up for free ASTRO membership in the “Student/Graduate Student/Post-Graduate Year (PGY)-1” membership category, which at the time of this study included a total of 382 United States and international medical students enrolled full-time in an accredited school of medicine, graduate students enrolled in a doctoral program, and PGY-1 residents. This database is routinely updated by ASTRO staff on a yearly basis by contacting all members to ask if they are still interested in RO, and those who are not are removed from the membership database. International students (n = 83) were excluded from this study. After obtaining institutional review board exemption, the survey was sent via email between July to August 2022 to the remaining 299 ASTRO Student/Graduate Student/PGY-1 members with a current US residence. Up to 3 reminder emails were sent to nonresponders, with a chance to win a $50 Amazon gift card offered with the final reminder email. All responses were anonymous.

Descriptive statistics are reported. The Mann-Whitney U test and Kruskal-Wallis test were used to compare the responses of subgroups of survey participants stratified according to their gender identity, race, ethnicity, family income, and baseline interest in applying for RO residency at the time of this survey (ie, already applied vs very/extremely likely to apply vs not at all/slightly/moderately likely to apply). As an exploratory objective, the Wilcoxon signed-rank test was used to compare all participants’ interest in different combined pathway programs compared with RO/IM, which was selected as the reference group since evaluation of a RO/IM pathway was the primary topic of the survey. A P value < .05 was considered statistically significant.

Results

A total of 80 medical students or PGY-1 residents responded (response rate 27%). The demographics of the participants can be found in Table 1. Fifty-two participants (65%) had not yet applied for RO residency, among which 26 (50%) believed that it was very or extremely likely that they would be applying for RO residency in the future.

Table 1.

Participant demographics

Characteristic	n (%)
Year in medical school
1-2	13 (16)
3-4	38 (48)
PGY-1 resident	27 (33)
Other	2 (3)
Degree program
MD	61 (76)
DO	3 (4)
MD/PhD	6 (8)
MD/MS	10 (12)
Already applied for radiation oncology residency
Yes	28 (35)
No	52 (65)
Medical school has radiation oncology department
Yes	66 (83)
No	14 (17)
Medical school has radiation oncology residency program
Yes	56 (70)
No	24 (30)
Gender identity
Cis male	47 (59)
Cis female	30 (37)
Prefer not to specify	3 (3)
Sexual orientation
Straight (heterosexual)	68 (85)
Bisexual	5 (6)
Gay or lesbian	4 (5)
Prefer not to specify	3 (3)
Race/ethnicity
White or Caucasian	33 (41)
Asian	23 (29)
Black or African American	8 (10)
Hispanic, Latinx, or of Spanish origin	8 (10)
Middle Eastern or North African	1 (1)
Native Hawaiian or Other Pacific Islander	1 (1)
Native American/American Indian or Alaska Native	2 (2)
Prefer not to specify	6 (8)
Family income during the past 10 years
<$50,000	11 (14)
$50,000-$100,0000	16 (20)
$100,001-$200,000	15 (19)
>$200,000	21 (26)
Prefer not to specify	17 (21)
Eligible for a federal Pell grant for financial aid during college
Yes	20 (25)
No	60 (75)
Have no (or had no) parents or legal guardians who completed a Bachelor's degree
Yes	10 (12)
No	70 (88)
Ideal work location after residency
Rural	1 (1)
Urban	40 (50)
Suburban	20 (25)
No preference	16 (20)
Other	3 (4)
Intention to work in medically underserved area after residency
Yes	18 (23)
No	16 (20)
Unsure	46 (57)

Abbreviation: PGY-1 = postgraduate year 1.

Thirty-four participants (43%) were either very or extremely interested in pursuing a combined IM/RO residency, whereas 20 (25%) were moderately interested, 12 (15%) were somewhat interested, and 14 (17%) were not at all interested (median Likert-type rating 3, IQR 2-4). The duration of a combined IM/RO training participants considered most preferable or ideal was 5 years for 57 participants (71%), 6 years for 21 participants (26%), and 7 years for 2 participants (3%). The most important potential advantages and disadvantages of a combined IM/RO pathway according to the participants are shown in Table 2. The most important potential advantages of an IM/RO pathway included greater flexibility in employment options (n = 51, 64%), enhanced general medical knowledge to facilitate ambitions in other career pathways (n = 46, 58%), improved patient care (n = 43, 54%), and having a pathway for combined hematologic/oncology and RO board certification (n = 46, 58%).

Table 2.

Participants were asked to select which of the potential advantages of a combined IM/RO training pathway would be most appealing, and what potential disadvantages would most dissuade them from applying to such a program

Question	n (%)
Potential advantages of a combined IM/RO pathway
Enhanced general medical knowledge for improved patient care	43 (54)
Enhanced general medical knowledge to facilitate ambitions in other career pathways	46 (58)
Greater flexibility in employment options	51 (64)
Pathway to combined hematologic/oncology and RO board certification	46 (58)
Other	5 (6)
Potential disadvantages of a combined IM/RO pathway
Additional years of training (beyond typical for IM alone or RO alone)	72 (90)
Need/obligation to acquire and maintain additional medical knowledge that I may not be using routinely	40 (50)
Pay difference between RO and IM	30 (38)
Other	3 (4)

Abbreviations: IM = internal medicine; RO = radiation oncology.

Participants’ interest in other types of combined pathway programs involving RO are shown in Table 3. In comparison to IM/RO, participants were significantly more interested in a combined RO and hematology/oncology program (P = .005), similarly interested in RO/radiology (P = .139), and significant less interested in all other options given (P < .001). Other options for combined pathway programs suggested by participants included palliative care (n = 2), interventional radiology (n = 2), urology (n = 2), pediatrics (n = 1), neurology (n = 1), family medicine (n = 1), gastroenterology (n = 1), endocrinology (n = 1), and hospital administration (n = 1).

Table 3.

Participants’ interest in a variety of combined pathway programs with radiation oncology

	Mean Likert-type score (SD)	Median Likert-type score (IQR)	P value in reference to RO/IM
RO/Internal Medicine	3.18 (1.41)	3 (2-4)	-
RO/Hematology-Oncology	4.29 (1.54)	5 (5-5)	.005
RO/Obstetrics-Gynecology	1.52 (1.36)	1 (1-1)	<.001
RO/Neurosurgery	1.49 (1.32)	1 (1-1)	<.001
RO/Nuclear Medicine	1.77 (1.61)	1 (1-1)	<.001
RO/Radiology	2.44 (1.96)	1 (1-5)	.139
RO/Surgery	1.60 (1.43)	1 (1-1)	<.001

Abbreviation: RO = radiation oncology.

Interest in a combined IM/RO residency was significantly lower (P = .009) among the 28 survey participants who had already applied for RO (median Likert-type rating 2, IQR 1-3) compared with the 26 participants who believed that it was less likely that they would apply (median Likert-type rating 3, IQR 2-4), or the 26 participants who believed that it was more likely that they would apply (median Likert-type rating 3, IQR 2-4). Among the subgroup of 26 participants who believed that it was less likely that they would be applying for RO residency, 18 (69%) believed that the availability of an IM/RO pathway would increase their interest in applying to RO (median Likert-type rating 4, IQR 3-5), and 17 (65%) believed that the availability of one of the other combined pathways would increase their interest in applying to RO (median Likert-type rating 4, IQR 3-5). No significant difference in interest for any of the proposed combined pathway programs was observed based on the sociodemographics assessed including family income, gender identity, race, or ethnicity.

Discussion

Currently there are no ACGME-accredited combined pathway programs involving any oncologic subspecialty. There is one involving radiology (diagnostic radiology/nuclear medicine),⁷ and the ACGME is also currently piloting a combined Hematology/Oncology and Hospice & Palliative Medicine Fellowship with 4 institutions. However, this pilot study has demonstrated that there is interest among some student and PGY-1 members of ASTRO in combined pathways between RO and either IM, hematology/oncology, or diagnostic radiology. Furthermore, our findings suggest that a combined pathway program may be particularly appealing to those who are interested in a career in RO but also seek a broader clinical skill set and more extensive scope of practice.

Importantly, the feasibility of these combined pathways would have to be carefully considered in the context of the length of time needed for adequate training to achieve the ACGME-defined competencies in each individual subspecialty. Since 1997 the standard RO residency has been 4 years in duration, after a 1-year internship. However, residents in the Holman Pathway, which is designed for select trainees who have both strong clinical and research abilities, allows for as little as 27 months of clinical training in RO to facilitate more extended research training.¹² This suggests that trainees with a strong clinical background may similarly be able to abbreviate their RO training for a combined pathway program. There also may be some room for a reduction in the duration of these other training programs when combined with RO; for instance, given the overlap in general medical content between a preliminary year in medicine and a categorical internal medicine residency, the multimodality imaging used in both RO and radiology, and knowledge of the pathophysiology of cancer for both RO and hematology/oncology. Within IM, there are accelerated programs where residents only complete 2 years of IM training rather than 3, before transitioning to fellowship training.¹³ An appropriate duration for a combined pathway program is critical for minimizing attrition due to the rigors of the training, including resident dropout from the second training component after completing the first.^14,15

Students should be selected conservatively for combined pathway programs, to minimize enrollment of those whose interest is based primarily on indecision because development of more interest for one field over the other after complete exposure to both specialties is also a common cause of attrition. This may, in part, account for our finding that survey participants who already applied to RO were less interested in a combined IM/RO pathway because they had already ruled out a more general medical field in favor of subspecialization. Currently, 1.5% of all GME trainees are in combined pathway programs, and it should similarly be relatively uncommon for future combinations with RO.⁷ In summary, although a combined pathway program may facilitate entry into radiation oncology for students with a genuine interest, it is unlikely to appreciably impact the supply of radiation oncologists in the workforce or contribute to any imbalance with the demand for radiation therapy.¹⁶

There are several important limitations of this work, the most important of which are the limited response rate and sample size of those surveyed, and inclusion of only student and PGY-1 members of ASTRO, both of which are associated with selection bias. As such, our findings should be considered preliminary and hypothesis-generating. Future directions include considering a more comprehensive survey of GME trainees in RO, IM, hematology-oncology, and diagnostic radiology, to better assess how the existence of a combined pathway between RO and each of these other specialties may impact career decision-making. Furthermore, obtaining a more mature perspective from early career RO attendings may be valuable, to assess whether they believe an IM/RO combined pathway would have been benefitted their career.

Conclusion

A combined training pathway between RO and IM, hematology-oncology, and diagnostic radiology is of interest to some student and PGY-1 members of ASTRO. Further research into innovative medical training-practice paradigms, which anticipates future public needs, and creates opportunities for interested students, will help inform data-driven recommendations to governing bodies such as the American Board of Radiology, American Board of Internal Medicine, and ACGME.

Disclosures

Malcolm D. Mattes receives grant funding from the Radiation Oncology Institute and Bristol Myers Squibb Foundation, and New Jersey Health Foundation. Neha Vapiwala leadership includes ASTRO Board of Directors, Secretary/Treasurer. Curtiland Deville's leadership includes ASTRO Board of Directors, Vice Chair, Council on Health Equity, Diversity & Inclusion. Idalid Franco receives grant funding from a Diversity Supplement through the National Institutes of Health, Center to Reduce Cancer Health Disparities (NIH-3R01CA240582-01A1S1), NIH/NCI Loan Repayment Program, and Career Development Award from the Center for Diversity and Inclusion of the Brigham and Women's Hospital.