Global Health Perspectives among Radiation Oncology Residency Program Directors: A Knowledge, Attitudes, and Practices Survey

Abstract

Purpose/Objective(s):

Global health interest has risen among medical students applying to and residents training in radiation oncology, often outpacing available educational offerings. The Association of Residents in Radiation Oncology (ARRO) Global Health Subcommittee (GHSC) sought to determine the perceptions of program directors (PDs) in radiation oncology and their current or planned global health curricular opportunities.

Materials/Methods:

A standardized, Knowledge, Attitudes and Practices (KAP) survey composed of 32 binary items was sent to PDs for all Accreditation Council for Graduate Medical Education (ACGME)-accredited radiation oncology programs.

Results:

Program response rate was 60% (55/91). Responding programs were distributed evenly geographically and included a range of training program sizes. Most PDs (77%) knew that most nations did not meet standard minimum benchmarks for radiation therapy access. While 89% would support residents to pursue global health rotations, only 22% would support departmental funding of such rotations. Further, 94% felt that global health was a field worthy of an academic career, but only 39% felt that it yet had appropriate rigor. Only 8% of programs had dedicated global health rotations.

Conclusion:

Radiation oncology PDs largely expressed favorable views of global health as a pursuit and affirmed a high degree of resident and medical student interest. However, faculty commitment and program offerings currently lag behind the interest level. In particular, a substantial number of program directors do not perceive that global health is yet a rigorous academic endeavor. Future progress in academic global health in radiation oncology will require strategies to systematically support pathways for development of experience and scholarship both within and beyond residency.

Introduction

Access to cancer care, particularly radiation therapy, is limited in low- and middle-income (LMIC) countries.¹ While there are many efforts originating in LMICs to address the growing cancer burden, financial and human resources in the health sector are often inadequate. ^1–8 In high-income countries (HICs), several specialties and sub-specialties such as infectious disease, primary care, and maternal and child health have well-established global health initiatives.^9–12 These often leverage research or clinical support from medical institutions in HICs to improve healthcare delivery in LMICs. Further, many offer opportunities for medical student and resident involvement in both short-term and long-term capacities.^13–16 There are dedicated global health residency tracks in a handful of institutions.¹⁶ Global oncology, in contrast, is an emerging field among HIC institutions.¹⁶Interest and efforts continue to grow over time, particularly among medical students and residents entering the field of radiation oncology. ^17–19

The Association for Residents in Radiation Oncology (ARRO) Global Health Subcommittee (GHSC), a branch of the executive committee dedicated to support and coordinate resident interest in global radiation oncology initiatives, was founded in 2009.¹⁹ A survey of radiation oncology resident interest in global health was conducted that year.¹⁹ While nearly 90% of responding residents reported interest in participating in global health efforts during their residency, only 10% reported educational opportunities in global health through their program. Further, the top barriers to participation listed were funding, elective time, and program director support. ¹⁹ Yet, an understanding of radiation oncology training program director perspectives on the role of global health remains limited. Thus, as ARRO GHSC proposed to update this initial resident survey, the group decided to simultaneously assess program perspectives on global health as there had been no baseline, systematic assessment of radiation oncology program views. The resident survey update shows sustained interest and an increase in resident-reported global initiatives in the intervening decade.²⁰ To assess the level of programmatic support in this era of high radiation oncology resident interest in global health, we herein report the results of the ARRO GHSC nationwide program director survey describing current program attitudes toward global health.

Methods and Materials

Program director (PD) global health surveys from other specialties were reviewed.^21–25 A survey following the Knowledge-Attitude-Practice (KAP) model and specific to radiation oncology was then developed with simple, binary items.^21–25Questions were escalated in the attitudes and practices sections from simplest to most complicated to support or implement. The survey was reviewed in detail by the two PD authors (NV, AZ) and revised. The survey experience - including link functionality, software usability, and completion time - and the face validity of the items was piloted by two additional PDs and modified further based on provided feedback. The final 32-item survey is available in the supplementary materials.

Radiation oncology programs and PDs were identified through the American Council for Graduate Medical Education (ACGME) public search for accredited programs located in the United States (US) as of December 2016.²⁶ US programs were surveyed for comparison with ARRO GHSC resident survey findings, where only residents in US programs were surveyed. PD names and contact details were verified by accessing individual program websites. Deputy, associate, and assistant PDs were also included where applicable.

The survey was administered securely through the Partners Health installation of LimeSurvey (LimeSurvey GmbH, Hamburg, Germany) in beginning in February 2017. No incentives were provided for survey completion. Unique survey tokens were automatically generated and sent by email to each program director in order to track programs response. The program directors were informed in the email and survey description that responses were confidential and that no identifying information about them or their program would be shared. Two automatically generated reminder emails were sent to non-respondents. Study authors sent one personalized email as a final request for completion. The survey was closed in May 2017. The study received exemption from the Partners Healthcare institutional review board.

Data were analyzed using STATA 14 (StataCorp LLC, College Station, Texas, USA) and Tableau (Tableau Software, Seattle, Washington, USA). ^27,28 Frequency statistics were represented numerically and graphically. For frequency statistics and correlations, each individual program director was counted for questions on individual knowledge as these were individual-level opinions for the program directors’ cohort. For all other questions on program support or educational offerings, the response of the highest-ranking program director was used if more than one response was received from a single program, as these were program-level considerations.

Results

The survey was sent to 111 individual program directors, including assistant and associate program directors for 91 unique programs. Individual response rate was 58% (64/111) and unique program response rate was 60% (55/91). Programs were located in 27 individual states and Washington, DC. There was representation from all four United States Census Bureau regions, with 22% (12) in the Northeast, 26% (14) in the Midwest, 26% (20) in the South, and 16% (9) in the West. Median number of residents per program was 8 (IQR: 6–11), with 20 programs with 6 or fewer residents, 23 programs with between 7 and 11 residents, and 12 programs 12 or more residents. Results by program size are reported in supplemental Table 1.

Global Health Knowledge

Program directors’ global health knowledge varied across the six true or false items regarding global health concepts and radiation oncology offerings. Among 64 individual PDs, 91% (58) were aware that the American Society for Radiation Oncology (ASTRO) offered funding for senior residents to pursue global health rotations (through ARRO). 80% (51) were aware that the American College of Radiology (ACR) offered global health funding. Most (77%, 49) knew that most nations did not yet meet the International Atomic Energy Agency (IAEA) minimum benchmark of one external beam therapy unit per million population. Most (59%, 38) knew that the American College of Graduate Medical Education (ACGME) allowed credit for rotations outside of the United States under certain conditions. A large minority (48%, 31) knew that the IAEA’s mandate for radiation therapy was primarily unrelated to the purchase of machines for low-income countries. Finally, 16% (10) knew that global health (as compared to international health) is a discipline focused on issues of health equity both outside of and within the United States and other high-income countries.

Global Health Attitudes and Practices

Among all 55 unique responding programs, favorable attitudes towards global health were generally reported. These are fully summarized in Figure 1. Most programs (94%, 52) judged medical student applicants with global health experience favorably, and 89% (49) reported that they would support residents to pursue one- to two-month clinical global health rotations if these were self-funded. However, only 22% (12) reported that they would support such rotations if they required departmental funding. A majority (61%, 34) would encourage residents to pursue long-term global health research. 94% felt that global health was a field worthy of an academic career, but only 39% (21) felt that it yet had appropriate rigor, per their interpretation. A significant minority of programs (41%, 23) expressed that at least 25% of their current residents were interested in global health.

Figure 1:

Summary of program attitudes to global health with “Yes” or “No” items. Questions have been truncated for readability. Full items available in supplemental materials. GH – Global Health. N=55 program responses with all programs responding to every question. Highest-ranking PD response was counted if multiple received.

Global health practices were more mixed (Figure 2). Only 8% (4) of programs reported that their program had dedicated global health rotations, and nearly half (48%, 26) reported that they currently supported resident participation in other institutions’ global health rotations. Some PDs (31%, 17) reported that there was funding for such rotations. The interpretation of what constituted a dedicated global health rotation was left to the discretion of program directors. While only 6% (3) of programs reported dedicated instruction in global radiation oncology, 76% (42) had the ability for residents to participate in global health education in other departments, and 42% (23) had at least one faculty member who was an identified as a global health mentor.

Figure 2:

Summary of program global health practices with “Yes” or “No” items. Questions have been truncated for readability. Full items available in supplemental materials. GH – Global Health. N=55 program responses with all programs responding to every question. GH – Global Health. N=55 program responses with all programs responding to every question. Highest-ranking PD response was counted if multiple received.

Future Directions

Among 55 unique programs, 80% (44) were interested in expanding global health offerings for their residents, while 64% (35) were interested in offering rotations to residents from low- and middle-income countries. A minority (17%, 9) reported that they were concerned that short term global health rotations abroad would strain the clinical obligations of residents in their home programs. Even fewer (9%, 5) reported concerns that the education or clinical experience of residents in host low- and middle-income countries could disrupted by short rotations. Most (90%, 50) respondents believed that global radiation oncology would be a meaningful avenue to reduce disparities in cancer outcomes. Yet, only 28% (15) expressed that they thought their program would have an interest in hiring new faculty or developing existing faculty to provide global health mentorship.

Program Director Comments

Several additional free text comments were submitted by program directors. Multiple comments reported that there was sufficient volume within their program thus ACGME case logs of rotations abroad would not be a barrier. One comment suggested that it is primarily the department chair’s responsibility to determine whether global health is supported in a residency program. Several comments described successful global partnerships established by residents or faculty. One comment described resident global health activity as “advanced medical tourism” while another reported that “global health” was not a well-defined term and instead a “meaningless locution.” As comments were generally brief and not mandatory, we could not apply a systematic, qualitative textual analysis.

Discussion

This represents the first, systematic analysis of the perspectives of United States radiation oncology training programs towards global radiation oncology. With a response rate of 60%, we found radiation oncology PDs largely expressed favorable views of global health as a pursuit and a meaningful level of resident interest. However, faculty commitment and program offerings reported remain modest. Further, the responses were geographically distributed and represented most of the residents nationally. Overall, PDs are providing opportunities for interested residents and are consider by medical student global interest favorably.

PDs were knowledgeable about the basics of radiation oncology access globally and the funding offerings of ASTRO and ACR. The starkest knowledge gap among PDs was that only 16% were correct with regard to the definition of global health. This is understandable, as the field of “global health” itself often struggles with a precise definition and is often used synonymously with “international health,” a predecessor term. ^29–32

To expand global health opportunities for interested, dedicated residents, there are a few potential areas of action for program directors that follow from the results of this survey and prior experience in other medical specialities.^10,11,13,15 First, is increasing resident knowledge about global health and global oncology. Radiation oncology programs that have sponsored residents to pursue global health research or service should share guidelines and resources to serve as models, as few are freely available.³³ARRO also has such information and it is freely accessible.³⁴ These guidelines or training materials could be offered to residents who express an interest in global health or more broadly to the entire residency cohort. Second, is improving mentorship ³⁴n global oncology. PDs could systematically refer interested residents to global oncology scholars in other departments or at other institutions. Additionally, PDs could identify mentors within their department who may not have global health expertise but are willing to mentor students from a general, career-development perspective. In this regard, PDs are well-poised to serve as bridge builders for global health scholars similar as they do with other more traditional research efforts pursued by their residents. One common challenge with respect to fields without well-worn pathways is the paucity of mentors who have followed the pathway under consideration, and thus a broader, creative mentorship approach could help to alleviate this fundamental issue. Thirdly, PDs that have global health programming could share such initiatives with interested PDs through a mechanism such as the Association of Directors in Radiation Oncology (ADROP) and perhaps in collaboration with ARRO’s GHSC to share “best practices” and collaborative models to ensure feasibility and sustainability.

Lastly, given the strong consensus from PDs that global health could be a mechanism to alleviate health disparities, bilateral opportunities should always be considered. ³⁵ This would allow LMIC trainees from partner programs to reap direct benefits from their institution’s participation through such formal arrangements. The predominance of virtual technologies makes online trainings or real-time, virtual contouring teaching possible alternatives to travel for all trainees. However, this should not preclude the consideration that trainees from LMICs may benefit significantly from on-site training experiences in HICs, and that these rotations may be the most beneficial for reducing health disparities and improving global health equity in cancer care. ^10,36–38 Further, program directors and others arranging short term global rotations must consider that they are often inherently disruptive to the clinical workflow and learning of resource-constrained departments.^15,39Trainees from HICs often overestimate their ability to meaningfully contribute, and underestimate the resources required to enable their learning experience.¹⁷ It is also worth noting that the enthusiasm of HIC medical students and residents may not translate into long-term career aspirations due to family or career constraints. ¹⁵ Careful consideration of the benefits of these experiences from the perspective of all stakeholders is important to avoid “advanced medical tourism” and the resultant “meaningless locution” as described by two program directors. ARRO and ADROP could consider collaborating to develop a policy on ethical rotations in global health to incorporate into the “best practices” document suggested above. Both could be voluntarily endorsed by radiation oncology residency programs.

As highlighted by one submitted comment, PDs are not solely responsible for shaping the learning environment and priorities of their residency. Chairpersons guide the larger vision for the department, overseeing faculty hiring and financial allocations. This may be particularly relevant with regard to the fact that while 89% of programs would support residents to pursue global health rotations, only 22% would support departmental funding of such rotations. More broadly still are the goals and resources of the cancer center and affiliate university, where applicable. The National Cancer Institute’s (NCI) Center for Global Health (CGH) recently completed a survey of global oncology activities at all NCI-designated cancer centers. ^40,41 The largest number were found in medical oncology, with radiation oncology as the second to last. This report highlights that radiation oncology departments lag behind in their global partnerships, but that there may be opportunities available for intra-institutional collaboration that have not been pursued. Notably, the NCI CGH focused on international collaborations, further obscuring the difference between global and international health disciplines.

Finally, there is the perennial issue of rigor in global health as integrated into academic radiation oncology. If academic global radiation oncology is a worthy pursuit, then it will need to be backed by two critical pillars of support that are often in short supply: time and money. These are certainly not sufficient to enhance rigor, but they are absolutely necessary. Rigorous scholarship requires protected time and financial support, as evidenced by the archetypical career development model for any physician-scientist. Global research is not so different, as prior reviews have demonstrated. ^15,42It requires time to build relationships, develop protocols, update infrastructure, hire and train supporting staff, and overcome challenges and delays inherent to the process. As with any field without a well-defined pathway, the progression toward rigor will likely be an iterative, and hopefully virtuous, cycle. Global radiation oncology scholars will continue to publish work completed on borrowed time without sufficient funding. The resultant work will hopefully encourage more dedicated funding and time and slowly enhance the overall rigor. Several recent publications have discussed possible pathways to streamline this creation of a novel career pathway in global oncology, including the logistical considerations of funding, protected time, and promotion.^43–45

Limitations

The conclusions are limited by several factors. First, the response rate, while reasonable at 60% does not preclude that there may be unmeasured, systematic differences between responders and non-responders. Second, there have been changes in program directors and program offerings since this survey was conducted, and so while this is relatively contemporary data, it has likely changed. Third, we were not able to compare reported program offerings with any comprehensive list. Gathering detailed data on program offerings was considered but decided against given the added survey burden lowering the likelihood of completion. Interestingly, several of the programs that are best known for their global health collaborations or rotations did not respond. Additionally, this survey does not exclude differences in global health efforts by program region or size, as larger numbers would likely be needed to uncover such differences. Finally, while program directors are critical stakeholders in the residency program, department chairs, cancer center leadership, and others also shape the training environment. We asked PDs for their synthesis and interpretation of program priorities, but further assessment of other stakeholder attitudes, particularly department chairs, is needed.

Conclusions

Global oncology interest has blossomed among trainees in radiation oncology. Program directors have been largely supportive of this development. Many radiation oncology programs support opportunities for their trainees, where possible, and identify key challenges to engagement in global health. The success of today’s trainees who are interested in the pursuit of global radiation oncology will depend on many factors outside of program support. Yet, program directors, department chairs, and others directly involved in residency education can continue to encourage the expansion of rigorous, equitable global health partnerships in radiation oncology in their programs and beyond.