International Journal of
Radiation Oncology biology
physics
www.redjournal.org
Education Original Article
Beyond the Standard Curriculum: A Review of Available Opportunities for Medical Students to Prepare for a Career in Radiation Oncology Ankit Agarwal, BA, Nicholas J. DeNunzio, BS, Divya Ahuja, BS, and Ariel E. Hirsch, MD Department of Radiation Oncology, Boston University School of Medicine, Boston, Massachusetts Received Feb 21, 2013, and in revised form Jul 31, 2013. Accepted for publication Aug 2, 2013.
Purpose: To review currently available opportunities for medical students to supplement their standard medical education to prepare for a career in radiation oncology. Methods and Materials: Google and PubMed were used to identify existing clinical, health policy, and research programs for medical students in radiation oncology. In addition, results publicly available by the National Resident Matching Program were used to explore opportunities that successful radiation oncology applicants pursued during their medical education, including obtaining additional graduate degrees. Results: Medical students can pursue a wide variety of opportunities before entering radiation oncology. Several national specialty societies, such as the American Society for Radiation Oncology and the Radiological Society of North America, offer summer internships for medical students interested in radiation oncology. In 2011, 30% of allopathic senior medical students in the United States who matched into radiation oncology had an additional graduate degree, including PhD, MPH, MBA, and MA degrees. Some medical schools are beginning to further integrate dedicated education in radiation oncology into the standard 4-year medical curriculum. Conclusions: To the authors’ knowledge, this is the first comprehensive review of available opportunities for medical students interested in radiation oncology. Early exposure to radiation oncology and additional educational training beyond the standard medical curriculum have the potential to create more successful radiation oncology applicants and practicing radiation oncologists while also promoting the growth of the field. We hope this review can serve as guide to radiation oncology applicants and mentors as well as encourage discussion regarding initiatives in radiation oncology opportunities for medical students. Ó 2014 Elsevier Inc.
Introduction The need for a greater emphasis on oncology, and radiation oncology specifically, in the medical curriculum is well documented (1-5). Recently, there have been reports on novel ways to integrate radiation oncology into the medical school curriculum and the impact of these educational innovations on students (6-8). These initiatives at individual medical schools have been well
Reprint requests to: Ariel E. Hirsch, MD, Department of Radiation Oncology, Boston University School of Medicine, Moakley Building,
Int J Radiation Oncol Biol Phys, Vol. 88, No. 1, pp. 39e44, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.08.003
received by students and have improved student knowledge of radiation oncology (6-10). Although these programs are undoubtedly beneficial for many medical students, those with a career interest in radiation oncology have additional opportunities available to them to augment their basic medical education and make them more competitive applicants to the field. Participation in national and international programs in research, clinical work, public policy, community service, and other areas are common ways that medical students
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Agarwal et al.
often seek to augment their basic medical education and be more competitive for admission in a competitive specialty such as radiation oncology. Among the most well-known programs are the Doris Duke Clinical Research Fellowship Program and the Howard Hughes Medical Institute Medical Research Fellows Program (11,12). Summer and year-long programs that are specific to certain specialties are also offered by many national medical societies in an effort to give medical students early exposure to their respective specialties (13-16). In addition, students can choose to pursue further education through graduate programs that provide skills and knowledge beyond what the traditional medical school curriculum emphasizes. Dual-degree programs at medical schools throughout the country, as well as external programs, have offered medical students the opportunity to pursue PhDs, MBAs, MPHs, and MPPs, among other degrees (17-19), which can promote essential physician advocacy, leadership, research, and/or involvement in public health (18,20-23). The purpose of this review is to identify the various opportunities available for medical students interested in radiation oncology to supplement their education to successfully prepare for applying to residency programs. Enumerating and organizing these opportunities is an important first step toward making these experiences more accessible to future medical students. This review will inform faculty and advisors of the current opportunities available and will, it is hoped, encourage faculty to create their own programs to further educational opportunities for students interested in radiation oncology.
Methods and Materials A comprehensive search of opportunities for medical students in radiation oncology was conducted using Google and PubMed. To identify programs, the search terms “radiation oncology,” “medical students,” “internship,” “summer,” “clinical,” “research,” and “health policy” were used. The results were stratified by type (clinical, research, and health policy), timeframe during medical education (preclinical and clinical years), and duration. We excluded programs that did not pertain to radiation oncology, had little to no public information available, or were no longer offered at the time this search was conducted. These opportunities for medical students are summarized in Table 1.
Table 1
In addition, data from the National Resident Matching Program (NRMP) were used to determine common characteristics of students who successfully match into radiation oncology. These results were used to explore other opportunities that successful radiation oncology applicants pursued during their medical education, including additional graduate degrees (13-15).
Results Research opportunities Three national research programs for medical students that specifically cater to radiation oncology were identified. The Radiological Society of North America (RSNA) offers funding for a full-time 10-week research project in a department of radiology, radiation oncology, or nuclear medicine. Every year, the RSNA funds approximately 25 medical students to work under the guidance of a faculty member at their own medical school or any other medical school in North America. Because these projects require full-time work, most students pursue these opportunities either during the summer between their first and second years of medical school or during a research elective, typically during their fourth year of medical school. The stated purpose of the program is to help develop medical students’ research skills and encourage them to consider a career in academic radiology, radiation oncology, and nuclear medicine (24). The American Society for Radiation Oncology (ASTRO) offers an 8-week Minority Summer Fellowship Award to students from underrepresented backgrounds to conduct research and gain clinical exposure to radiation oncology. ASTRO provides funding to first-year and second-year medical students enrolled at accredited medical schools in the United States. In addition, the program provides travel funding to attend the next annual ASTRO meeting. Most students pursue the fellowship between their first and second years of medical school. Students selected for the program undertake a research project and gain other clinical experience by working with a mentor in their radiation oncology department (25). Thomas Jefferson University Hospital, the University of Maryland, and the University of Pittsburgh Cancer Institute offer a 6-week Simon Kramer Externship in Radiation Oncology. The program is open to first-year and second-year students from accredited medical schools in the United States, and students
National radiation oncology programs for medical students
Characteristic
RSNA
Research Clinical Policy Duration (wk) Most common time during medical school
X
10 Research elective or summer
ASTRO minority scholars
Simon Kramer externship
X X
X X
8 Summer after 1st year
6 Summer after 1st year
AMA/ASTRO GRIP
HHMI medical research fellows program X
X 6 Summer after 1st year
8-10 or 52 Summer after 1st year or during 1-year break from medical school
Abbreviations: AMA Z American Medical Association; ASTRO Z American Society for Radiation Oncology; GRIP Z government relationship internship program; HHMI Z Howard Hughes Medical Institute; RSNA Z Radiological Society of North America.
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generally pursue the program during the summer between their first and second years in medical school. Students in the program are assigned to a mentor and work on a clinical research project. In addition, students in the program generally attend planning conferences, lectures, and seminars, and they gain clinical exposure to radiation oncology by shadowing physicians (26-28).
that integrates courses in radiation therapy with research opportunities. Interested students can further pursue a DPhil (PhD) in radiobiology from the University of Oxford (32). Although other programs in radiation biology exist throughout the United States, most of these programs are graduate degrees in physics departments and do not specifically focus on radiation oncology.
Policy opportunities
Other graduate degrees
Medical students can also pursue their interest in radiation oncology through health policy opportunities. The American Medical Association (AMA), in conjunction with ASTRO, offers a government relations internship program (GRIP) for medical students. The 6-week AMA/ASTRO GRIP program places medical students in Washington, DC, to work with ASTRO’s government relations office on legislation affecting the practice of radiation oncology. Students generally participate during the summer between their first and second years of medical school. During the program, students attend weekly seminars at the AMA office in the District of Columbia on various policy topics affecting the practice of medicine. Throughout the program, students learn about issues affecting the current practice of radiation oncology and become effective advocates through their work in the government relations department (29).
Over the past 30 years, an increasing number of medical students have pursued additional graduate degrees. The most common degrees, after a PhD, are the MPH and the MBA. From 1994 to 1995, 35 schools offered an MD-MPH program, and 13 schools offered an MD-MBA program (33). By 2011, 86 medical schools offered an MD-MPH program and 65 schools offered an MDMBA program (17, 34).
Discussion The number of residency positions available in radiation oncology has grown from 81 in 2001 to 171 in 2011 and 2012 (30,35). Despite this increase, matching to a radiation oncology residency program in the United States remains highly competitive. In 2012, of the 171 residency spots offered in radiation oncology, 170 (99.4%) were filled (30). Among seniors in the United States who designated radiation oncology as their only choice, 14% (23 of 163) did not match in 2011. Among specialties offering more than 20 spots in 2011, only dermatology, general surgery, orthopedic surgery, and plastic surgery had higher unmatched rates, with 15%, 15%, 20%, and 26%, respectively. Among successful applicants to radiation oncology in the United States, the mean USMLE Step 1 score was 240, and the mean USMLE Step 2 score was 244. The national means for accepted students to all specialties were 226 and 235 respectively (36). Among seniors in the United States who successfully matched into radiation oncology, applicants had a mean number of 8.3 abstracts, presentations, and publications, which was the highest among all specialties (35). Given the competitive nature of the radiation oncology match process, it is not surprising that students seek additional opportunities outside of the traditional medical curriculum. Radiation oncology is a specialty that places a premium on research skills, as reflected by various metrics tracked by the NRMP. The fact that many radiation oncology residency programs have up to 1 year of protected research time for their residents is testament to the importance of research in radiation oncology. The development of effective research skills through summer programs such as those outlined here is essential in training future radiation oncologists.
Education programs According to the 2011 NRMP Charting Outcomes, 30% of US allopathic senior medical students who matched into radiation oncology had an additional graduate degree, compared with 11% in all specialties. Of the 30% who had an additional graduate degree, 22.1% had a PhD, and 7.8% had another graduate degree, such as an MPH, MBA, or MA/MS, in various disciplines (30). Table 2 displays the most relevant additional degrees and some of the skillsets emphasized by each. According to the Association of American Medical Colleges, 121 schools in the United States currently offer MD-PhD programs (31). MD-PhD programs typically aim to train physician-scientists in a 7-year to 8-year curriculum that offers the traditional 4-year MD training along with 3 to 4 years of exposure to research.
Graduate degrees in radiation oncology Most students who obtain additional graduate degrees do not complete them in fields directly related to radiation oncology. However, 1 program does specialize in radiation therapy as it relates to cancer care. The Gray Institute for Radiation Oncology and Biology at the University of Oxford offers a 1-year program
Table 2
Educational opportunities for medical students
Educational program
PhD
Research Leadership Public health Duration (y) Most common time during medical school
X
MBA
MPH
MA in radiobiology (Oxford) X
X 3-4 Between years 2 and 3
1-2 Between years 3 and 4
X 1-2 Between years 3 and 4
1 Between years 3 and 4
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Furthermore, early exposure to a specialty has a demonstrated effect on specialty choice. Medical students who receive greater exposure to primary care are more likely to choose primary care, and students who are exposed to negative comments about primary care by faculty and residents are less likely to choose primary care (37-39). Kubal et al (40) showed that participation in a formal family medicine preceptorship program for 4 weeks between students’ first and second years of medical school increased medical student selection of a family medicine residency. Johnson et al (41) analyzed medical student selection of orthopedic surgery as a career and concluded that positive clinical role models and additional experiences in orthopedic surgery during medical school enhance medical student selection of orthopedic surgery as a career. Similar results of early exposure and specialty choice have been shown in radiation oncology. The Ivan H. Smith Memorial Studentship (ISMS) program, established in 1962 at the University of Western Ontario and discontinued in 2012, provided medical students with clinical experience in radiation oncology. Medical students generally pursued the program between their first and second years of medical school for 8 weeks, working with several radiation oncologists in different clinics to gain exposure to a variety of primary tumors and treatment modalities. Barrett et al (42) tracked students who participated in the ISMS program between 1971 and 1981 to determine whether participation in the program affected their choice of specialty. The results showed that participants in the program were nearly 6 times as likely as their medical student peers to train in radiation oncology. It is clear that creating opportunities for medical students to gain more experience in a chosen specialty is associated with greater student selection of the given specialty as a career choice. Professional medical societies have also increasingly come to realize the importance of organized political advocacy. In 2003, ASTRO created ASTRO PAC, a federal political action committee that is responsible for advocating on behalf of the field of radiation oncology through the political process. In addition, ASTRO maintains a government relations committee, consisting of practicing radiation oncologists and radiation oncology residents, which holds meetings regularly to discuss political and policy developments that have the potential to affect radiation oncology. Many medical leaders now recognize advocacy as an important professional competence among physicians and realize the need for better education in health policy and advocacy (43-46). Accordingly, the prevalence of formal legislative and advocacy experiences for residents and attending physicians has grown in recent years (47-50). New York University’s radiation oncology residency program recently implemented courses in health policy, finance, and law for radiation oncology residents in addition to encouraging residents to attend ASTRO’s annual advocacy day. Surveys and assessments of the residents showed a significant increase in knowledge, and 4 of the 6 residents participating in the program agreed that it is important for physicians to be involved in health policy (51). The introduction of new technology such as intensity-modulated radiation therapy and proton therapy pose tremendous potential benefits to patients; however, unstable reimbursement rates and questionable utilization patterns in some practice settings reveal an uncertain future for these and future technologies (52-56). In addition, given the rise of changing practice and payment models such as accountable care organizations and bundled payments, the introduction of radiation patient safety legislation, and the rapid evolution of radiation oncology as
International Journal of Radiation Oncology Biology Physics a field, the existence of radiation oncologist leaders who are able to address these issues is critical (57, 58). Policy experience gained through the GRIP program will train future radiation oncologists to be effective leaders in the advocacy process on behalf of radiation oncology. Although advocacy and knowledge of public policy have more recently become important among radiation oncologists, radiation oncology has always valued well-developed research skills. Accordingly, radiation oncology is especially attractive to students with PhD degrees because of the availability of field-specific research opportunities and in oncology more generally. Given the quickly evolving nature of radiation oncology with regard to research and technology, it is essential for all practicing radiation oncologists to stay current with research in the field. Another way for students to deepen their understanding of radiation oncology and radiation biology is through the 1-year program at the Gray Institute for Radiation Oncology and Biology at the University of Oxford. This program has the potential to make medical students more effective radiation oncology researchers and instructors in the future. Given the enormous impact of cancer on public health in the United States, an MPH can give medical students the tools to conduct epidemiologic studies in cancer and radiation therapy to become leaders in cancer care beyond their own patient populations. A formal business education through an MBA gives future physicians the business and leadership skills to more effectively manage large, multidisciplinary practices; implement quality improvement and comparative effectiveness research in practice; and serve as effective leaders in the field (59). In addition, with the introduction of accountable care organizations, oncology patient-centered medical homes, and a greater emphasis coordination of care, radiation oncologists who are trained in organizational behavior and team management will have the potential to be more effective clinicians (60-63). Nationally available programs for medical students interested in radiation oncology and the pursuit of additional formal education are important ways to cultivate future radiation oncologists. However, individual medical schools can also take steps to improve radiation oncology offerings for their own medical students. At our institution, students can explore research in radiation oncology through the Medical Student Summer Research Program, which was developed to provide a structured research environment for medical students to conduct research between their first and second years of medical school. Medical students participate in research in many fields, including radiation oncology, that often result in poster and oral presentations at national conferences such as the ASTRO and RSNA annual meetings. Several other medical schools offer similar summer research programs. In addition, our institution’s Oncology Education Initiative exposes students to the field of radiation oncology through vertically integrated preclinical and clinical teaching (6, 7, 64, 65). Other medical schools, such as Jefferson Medical College and Duke University School of Medicine, have also documented the benefits of adding radiation oncology to the clinical curriculum in medical school (8, 66). According to the Association of American Medical Colleges, 15 allopathic medical schools in the United States currently offer radiation oncology as part of their medical school curricula (67). Students would benefit by the introduction of such radiation oncology educational and research programs at medical schools across the country. We also encourage medical schools with existing programs to share the results of such
Volume 88 Number 1 2014 initiatives to help educators elsewhere develop new and effective programs.
Conclusion Supplementary programs can train future radiation oncologists to be leaders in both radiation oncology and the medical profession in general. The opportunities we have outlined will help mentors in radiation oncology and aspiring radiation oncology students understand which available experiences will help them gain exposure to radiation oncology early in medical school. Most of the structured radiation oncology-specific programs are limited to the first summer after medical school, owing to both medical school student schedules and the limited availability of radiation oncology-specific programs. Aspiring radiation oncologists could benefit from the development of more summer radiation oncology programs and from more educational programs in radiation oncology, such as the program at the Gray Institute for Radiation Oncology and Biology at the University of Oxford. In addition, radiation oncology faculty at medical schools can use the models described here to prepare students for a career in radiation oncology in lieu of a formally established program. We have attempted to begin codifying the opportunities available for current medical students pursuing a career in radiation oncology, and we hope this effort will encourage others to develop and share their own radiation oncology initiatives for medical students as we train the next generation of radiation oncologists.
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Radiation Oncology biology
physics
www.redjournal.org
Education Original Article
Beyond the Standard Curriculum: A Review of Available Opportunities for Medical Students to Prepare for a Career in Radiation Oncology Ankit Agarwal, BA, Nicholas J. DeNunzio, BS, Divya Ahuja, BS, and Ariel E. Hirsch, MD Department of Radiation Oncology, Boston University School of Medicine, Boston, Massachusetts Received Feb 21, 2013, and in revised form Jul 31, 2013. Accepted for publication Aug 2, 2013.
Purpose: To review currently available opportunities for medical students to supplement their standard medical education to prepare for a career in radiation oncology. Methods and Materials: Google and PubMed were used to identify existing clinical, health policy, and research programs for medical students in radiation oncology. In addition, results publicly available by the National Resident Matching Program were used to explore opportunities that successful radiation oncology applicants pursued during their medical education, including obtaining additional graduate degrees. Results: Medical students can pursue a wide variety of opportunities before entering radiation oncology. Several national specialty societies, such as the American Society for Radiation Oncology and the Radiological Society of North America, offer summer internships for medical students interested in radiation oncology. In 2011, 30% of allopathic senior medical students in the United States who matched into radiation oncology had an additional graduate degree, including PhD, MPH, MBA, and MA degrees. Some medical schools are beginning to further integrate dedicated education in radiation oncology into the standard 4-year medical curriculum. Conclusions: To the authors’ knowledge, this is the first comprehensive review of available opportunities for medical students interested in radiation oncology. Early exposure to radiation oncology and additional educational training beyond the standard medical curriculum have the potential to create more successful radiation oncology applicants and practicing radiation oncologists while also promoting the growth of the field. We hope this review can serve as guide to radiation oncology applicants and mentors as well as encourage discussion regarding initiatives in radiation oncology opportunities for medical students. Ó 2014 Elsevier Inc.
Introduction The need for a greater emphasis on oncology, and radiation oncology specifically, in the medical curriculum is well documented (1-5). Recently, there have been reports on novel ways to integrate radiation oncology into the medical school curriculum and the impact of these educational innovations on students (6-8). These initiatives at individual medical schools have been well
Reprint requests to: Ariel E. Hirsch, MD, Department of Radiation Oncology, Boston University School of Medicine, Moakley Building,
Int J Radiation Oncol Biol Phys, Vol. 88, No. 1, pp. 39e44, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.08.003
received by students and have improved student knowledge of radiation oncology (6-10). Although these programs are undoubtedly beneficial for many medical students, those with a career interest in radiation oncology have additional opportunities available to them to augment their basic medical education and make them more competitive applicants to the field. Participation in national and international programs in research, clinical work, public policy, community service, and other areas are common ways that medical students
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often seek to augment their basic medical education and be more competitive for admission in a competitive specialty such as radiation oncology. Among the most well-known programs are the Doris Duke Clinical Research Fellowship Program and the Howard Hughes Medical Institute Medical Research Fellows Program (11,12). Summer and year-long programs that are specific to certain specialties are also offered by many national medical societies in an effort to give medical students early exposure to their respective specialties (13-16). In addition, students can choose to pursue further education through graduate programs that provide skills and knowledge beyond what the traditional medical school curriculum emphasizes. Dual-degree programs at medical schools throughout the country, as well as external programs, have offered medical students the opportunity to pursue PhDs, MBAs, MPHs, and MPPs, among other degrees (17-19), which can promote essential physician advocacy, leadership, research, and/or involvement in public health (18,20-23). The purpose of this review is to identify the various opportunities available for medical students interested in radiation oncology to supplement their education to successfully prepare for applying to residency programs. Enumerating and organizing these opportunities is an important first step toward making these experiences more accessible to future medical students. This review will inform faculty and advisors of the current opportunities available and will, it is hoped, encourage faculty to create their own programs to further educational opportunities for students interested in radiation oncology.
Methods and Materials A comprehensive search of opportunities for medical students in radiation oncology was conducted using Google and PubMed. To identify programs, the search terms “radiation oncology,” “medical students,” “internship,” “summer,” “clinical,” “research,” and “health policy” were used. The results were stratified by type (clinical, research, and health policy), timeframe during medical education (preclinical and clinical years), and duration. We excluded programs that did not pertain to radiation oncology, had little to no public information available, or were no longer offered at the time this search was conducted. These opportunities for medical students are summarized in Table 1.
Table 1
In addition, data from the National Resident Matching Program (NRMP) were used to determine common characteristics of students who successfully match into radiation oncology. These results were used to explore other opportunities that successful radiation oncology applicants pursued during their medical education, including additional graduate degrees (13-15).
Results Research opportunities Three national research programs for medical students that specifically cater to radiation oncology were identified. The Radiological Society of North America (RSNA) offers funding for a full-time 10-week research project in a department of radiology, radiation oncology, or nuclear medicine. Every year, the RSNA funds approximately 25 medical students to work under the guidance of a faculty member at their own medical school or any other medical school in North America. Because these projects require full-time work, most students pursue these opportunities either during the summer between their first and second years of medical school or during a research elective, typically during their fourth year of medical school. The stated purpose of the program is to help develop medical students’ research skills and encourage them to consider a career in academic radiology, radiation oncology, and nuclear medicine (24). The American Society for Radiation Oncology (ASTRO) offers an 8-week Minority Summer Fellowship Award to students from underrepresented backgrounds to conduct research and gain clinical exposure to radiation oncology. ASTRO provides funding to first-year and second-year medical students enrolled at accredited medical schools in the United States. In addition, the program provides travel funding to attend the next annual ASTRO meeting. Most students pursue the fellowship between their first and second years of medical school. Students selected for the program undertake a research project and gain other clinical experience by working with a mentor in their radiation oncology department (25). Thomas Jefferson University Hospital, the University of Maryland, and the University of Pittsburgh Cancer Institute offer a 6-week Simon Kramer Externship in Radiation Oncology. The program is open to first-year and second-year students from accredited medical schools in the United States, and students
National radiation oncology programs for medical students
Characteristic
RSNA
Research Clinical Policy Duration (wk) Most common time during medical school
X
10 Research elective or summer
ASTRO minority scholars
Simon Kramer externship
X X
X X
8 Summer after 1st year
6 Summer after 1st year
AMA/ASTRO GRIP
HHMI medical research fellows program X
X 6 Summer after 1st year
8-10 or 52 Summer after 1st year or during 1-year break from medical school
Abbreviations: AMA Z American Medical Association; ASTRO Z American Society for Radiation Oncology; GRIP Z government relationship internship program; HHMI Z Howard Hughes Medical Institute; RSNA Z Radiological Society of North America.
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generally pursue the program during the summer between their first and second years in medical school. Students in the program are assigned to a mentor and work on a clinical research project. In addition, students in the program generally attend planning conferences, lectures, and seminars, and they gain clinical exposure to radiation oncology by shadowing physicians (26-28).
that integrates courses in radiation therapy with research opportunities. Interested students can further pursue a DPhil (PhD) in radiobiology from the University of Oxford (32). Although other programs in radiation biology exist throughout the United States, most of these programs are graduate degrees in physics departments and do not specifically focus on radiation oncology.
Policy opportunities
Other graduate degrees
Medical students can also pursue their interest in radiation oncology through health policy opportunities. The American Medical Association (AMA), in conjunction with ASTRO, offers a government relations internship program (GRIP) for medical students. The 6-week AMA/ASTRO GRIP program places medical students in Washington, DC, to work with ASTRO’s government relations office on legislation affecting the practice of radiation oncology. Students generally participate during the summer between their first and second years of medical school. During the program, students attend weekly seminars at the AMA office in the District of Columbia on various policy topics affecting the practice of medicine. Throughout the program, students learn about issues affecting the current practice of radiation oncology and become effective advocates through their work in the government relations department (29).
Over the past 30 years, an increasing number of medical students have pursued additional graduate degrees. The most common degrees, after a PhD, are the MPH and the MBA. From 1994 to 1995, 35 schools offered an MD-MPH program, and 13 schools offered an MD-MBA program (33). By 2011, 86 medical schools offered an MD-MPH program and 65 schools offered an MDMBA program (17, 34).
Discussion The number of residency positions available in radiation oncology has grown from 81 in 2001 to 171 in 2011 and 2012 (30,35). Despite this increase, matching to a radiation oncology residency program in the United States remains highly competitive. In 2012, of the 171 residency spots offered in radiation oncology, 170 (99.4%) were filled (30). Among seniors in the United States who designated radiation oncology as their only choice, 14% (23 of 163) did not match in 2011. Among specialties offering more than 20 spots in 2011, only dermatology, general surgery, orthopedic surgery, and plastic surgery had higher unmatched rates, with 15%, 15%, 20%, and 26%, respectively. Among successful applicants to radiation oncology in the United States, the mean USMLE Step 1 score was 240, and the mean USMLE Step 2 score was 244. The national means for accepted students to all specialties were 226 and 235 respectively (36). Among seniors in the United States who successfully matched into radiation oncology, applicants had a mean number of 8.3 abstracts, presentations, and publications, which was the highest among all specialties (35). Given the competitive nature of the radiation oncology match process, it is not surprising that students seek additional opportunities outside of the traditional medical curriculum. Radiation oncology is a specialty that places a premium on research skills, as reflected by various metrics tracked by the NRMP. The fact that many radiation oncology residency programs have up to 1 year of protected research time for their residents is testament to the importance of research in radiation oncology. The development of effective research skills through summer programs such as those outlined here is essential in training future radiation oncologists.
Education programs According to the 2011 NRMP Charting Outcomes, 30% of US allopathic senior medical students who matched into radiation oncology had an additional graduate degree, compared with 11% in all specialties. Of the 30% who had an additional graduate degree, 22.1% had a PhD, and 7.8% had another graduate degree, such as an MPH, MBA, or MA/MS, in various disciplines (30). Table 2 displays the most relevant additional degrees and some of the skillsets emphasized by each. According to the Association of American Medical Colleges, 121 schools in the United States currently offer MD-PhD programs (31). MD-PhD programs typically aim to train physician-scientists in a 7-year to 8-year curriculum that offers the traditional 4-year MD training along with 3 to 4 years of exposure to research.
Graduate degrees in radiation oncology Most students who obtain additional graduate degrees do not complete them in fields directly related to radiation oncology. However, 1 program does specialize in radiation therapy as it relates to cancer care. The Gray Institute for Radiation Oncology and Biology at the University of Oxford offers a 1-year program
Table 2
Educational opportunities for medical students
Educational program
PhD
Research Leadership Public health Duration (y) Most common time during medical school
X
MBA
MPH
MA in radiobiology (Oxford) X
X 3-4 Between years 2 and 3
1-2 Between years 3 and 4
X 1-2 Between years 3 and 4
1 Between years 3 and 4
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Furthermore, early exposure to a specialty has a demonstrated effect on specialty choice. Medical students who receive greater exposure to primary care are more likely to choose primary care, and students who are exposed to negative comments about primary care by faculty and residents are less likely to choose primary care (37-39). Kubal et al (40) showed that participation in a formal family medicine preceptorship program for 4 weeks between students’ first and second years of medical school increased medical student selection of a family medicine residency. Johnson et al (41) analyzed medical student selection of orthopedic surgery as a career and concluded that positive clinical role models and additional experiences in orthopedic surgery during medical school enhance medical student selection of orthopedic surgery as a career. Similar results of early exposure and specialty choice have been shown in radiation oncology. The Ivan H. Smith Memorial Studentship (ISMS) program, established in 1962 at the University of Western Ontario and discontinued in 2012, provided medical students with clinical experience in radiation oncology. Medical students generally pursued the program between their first and second years of medical school for 8 weeks, working with several radiation oncologists in different clinics to gain exposure to a variety of primary tumors and treatment modalities. Barrett et al (42) tracked students who participated in the ISMS program between 1971 and 1981 to determine whether participation in the program affected their choice of specialty. The results showed that participants in the program were nearly 6 times as likely as their medical student peers to train in radiation oncology. It is clear that creating opportunities for medical students to gain more experience in a chosen specialty is associated with greater student selection of the given specialty as a career choice. Professional medical societies have also increasingly come to realize the importance of organized political advocacy. In 2003, ASTRO created ASTRO PAC, a federal political action committee that is responsible for advocating on behalf of the field of radiation oncology through the political process. In addition, ASTRO maintains a government relations committee, consisting of practicing radiation oncologists and radiation oncology residents, which holds meetings regularly to discuss political and policy developments that have the potential to affect radiation oncology. Many medical leaders now recognize advocacy as an important professional competence among physicians and realize the need for better education in health policy and advocacy (43-46). Accordingly, the prevalence of formal legislative and advocacy experiences for residents and attending physicians has grown in recent years (47-50). New York University’s radiation oncology residency program recently implemented courses in health policy, finance, and law for radiation oncology residents in addition to encouraging residents to attend ASTRO’s annual advocacy day. Surveys and assessments of the residents showed a significant increase in knowledge, and 4 of the 6 residents participating in the program agreed that it is important for physicians to be involved in health policy (51). The introduction of new technology such as intensity-modulated radiation therapy and proton therapy pose tremendous potential benefits to patients; however, unstable reimbursement rates and questionable utilization patterns in some practice settings reveal an uncertain future for these and future technologies (52-56). In addition, given the rise of changing practice and payment models such as accountable care organizations and bundled payments, the introduction of radiation patient safety legislation, and the rapid evolution of radiation oncology as
International Journal of Radiation Oncology Biology Physics a field, the existence of radiation oncologist leaders who are able to address these issues is critical (57, 58). Policy experience gained through the GRIP program will train future radiation oncologists to be effective leaders in the advocacy process on behalf of radiation oncology. Although advocacy and knowledge of public policy have more recently become important among radiation oncologists, radiation oncology has always valued well-developed research skills. Accordingly, radiation oncology is especially attractive to students with PhD degrees because of the availability of field-specific research opportunities and in oncology more generally. Given the quickly evolving nature of radiation oncology with regard to research and technology, it is essential for all practicing radiation oncologists to stay current with research in the field. Another way for students to deepen their understanding of radiation oncology and radiation biology is through the 1-year program at the Gray Institute for Radiation Oncology and Biology at the University of Oxford. This program has the potential to make medical students more effective radiation oncology researchers and instructors in the future. Given the enormous impact of cancer on public health in the United States, an MPH can give medical students the tools to conduct epidemiologic studies in cancer and radiation therapy to become leaders in cancer care beyond their own patient populations. A formal business education through an MBA gives future physicians the business and leadership skills to more effectively manage large, multidisciplinary practices; implement quality improvement and comparative effectiveness research in practice; and serve as effective leaders in the field (59). In addition, with the introduction of accountable care organizations, oncology patient-centered medical homes, and a greater emphasis coordination of care, radiation oncologists who are trained in organizational behavior and team management will have the potential to be more effective clinicians (60-63). Nationally available programs for medical students interested in radiation oncology and the pursuit of additional formal education are important ways to cultivate future radiation oncologists. However, individual medical schools can also take steps to improve radiation oncology offerings for their own medical students. At our institution, students can explore research in radiation oncology through the Medical Student Summer Research Program, which was developed to provide a structured research environment for medical students to conduct research between their first and second years of medical school. Medical students participate in research in many fields, including radiation oncology, that often result in poster and oral presentations at national conferences such as the ASTRO and RSNA annual meetings. Several other medical schools offer similar summer research programs. In addition, our institution’s Oncology Education Initiative exposes students to the field of radiation oncology through vertically integrated preclinical and clinical teaching (6, 7, 64, 65). Other medical schools, such as Jefferson Medical College and Duke University School of Medicine, have also documented the benefits of adding radiation oncology to the clinical curriculum in medical school (8, 66). According to the Association of American Medical Colleges, 15 allopathic medical schools in the United States currently offer radiation oncology as part of their medical school curricula (67). Students would benefit by the introduction of such radiation oncology educational and research programs at medical schools across the country. We also encourage medical schools with existing programs to share the results of such
Volume 88 Number 1 2014 initiatives to help educators elsewhere develop new and effective programs.
Conclusion Supplementary programs can train future radiation oncologists to be leaders in both radiation oncology and the medical profession in general. The opportunities we have outlined will help mentors in radiation oncology and aspiring radiation oncology students understand which available experiences will help them gain exposure to radiation oncology early in medical school. Most of the structured radiation oncology-specific programs are limited to the first summer after medical school, owing to both medical school student schedules and the limited availability of radiation oncology-specific programs. Aspiring radiation oncologists could benefit from the development of more summer radiation oncology programs and from more educational programs in radiation oncology, such as the program at the Gray Institute for Radiation Oncology and Biology at the University of Oxford. In addition, radiation oncology faculty at medical schools can use the models described here to prepare students for a career in radiation oncology in lieu of a formally established program. We have attempted to begin codifying the opportunities available for current medical students pursuing a career in radiation oncology, and we hope this effort will encourage others to develop and share their own radiation oncology initiatives for medical students as we train the next generation of radiation oncologists.
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