t .I0
0360-3016192 $5.00 Copyright G 1992 Pergamon Press Ltd.
Vol.24,PP. 987-988
In1 J. Radiarm Oncoloyy RIO/. Phys Printed in the U.S.A All rights reserved.
??Editorial
SUBSPECIALIZATION
IN RADIATION
ONCOLOGY
JAMES E. MARKS, M.D. Dept. of Radiotherapy,
Loyola University
Medical Ctr., 2 160 South First Ave., Maywood,
dual bodies in the United States. The Accreditation Council for Graduate Medical Education accredits training programs in the United States and the Boards of Medical Specialties certify the individual. Those responsible for accreditation don’t necessarily act in concert with those responsible for certification. In fact, ACGME held a special conference entitled, “Accreditation Without Certification” whose purpose was to better define and coordinate the processes of accreditation and certification. The Accreditation Council for Graduate Medical Education required communication between the Residency Review Committee for the specialty and the relevant board concerning the establishment of a new subspecialty and documentation that the board would or would not award a certificate in that subspecialty. The Accreditation Council for Graduate Medical Education was willing to consider accreditation of a subspecialty even if the board opposed it provided the subspecialty met all guidelines required for subspecialty recognition. Clearly though, ACGME preferred that a board recognize a particular subspecialty and be willing to certify graduates of accredited programs. In the case of Radiology, ACGME accreditation of Pediatric Radiology, Neuroradiology, Vascular and Interventional Radiology was followed closely by a decision of the American Board of Radiology to offer Certificates of Added Qualifications in these subspecialty areas (Communication to program directors and departmental chairman from Thomas F. Meaney, M.D., President of the American Board of Radiology, 5/7/92). Thus, the processes of accreditation and certification for the new subspecialty areas of Radiology were closely coordinated by members of the Residency Review Committee and the American Board of Radiology. This was largely possible because the American Board of Radiology has several members on the Residency Review Committee and regularly participates in the accreditation process. The progressive fragmentation of medicine into more and more medical specialties is viewed differently by the patient, the trainee, and faculty member. The faculty member who is responsible for advancing knowledge
In 1972, when I was certified by the American Board of Radiology to practice the subspecialty therapeutic radiology, there were 29 separate specialties in American medicine. Today, 20 years later, there are a total of 75 separate specialties listed in the AMA Directory of Graduate Medical Education Programs. Each specialty has its own special requirements for training in that particular field of medicine. The tendency for medicine to fragment into subspecialty parts resulted from an enormous growth in medical knowledge and the recognition that a single physician could not learn all areas of medicine. Practitioners developed areas of special expertise within broad disciplines and faculty become subspecialized as they pursued their research and developed special areas of knowledge within the specialty. Internal medicine was the earliest to divide itself into subspecialty areas and served as an example for other specialties that sought to develop subspecialty training programs. Internal medicine with eleven subspecialty programs is followed by Pathology with eight, Pediatrics with seven, Orthopedics with six, Surgery with four, and Radiology with four. Radiology first recognized Nuclear Radiology and Radiation Oncology as separate subspecialties and only recently has developed separate accreditation for Pediatric Radiology, Neuroradiology, and Vascular and Interventional Radiology. The recent proliferation of so many subspecialties in medicine posed an enormous workload for the Accreditation Council for Graduate Medical Education (ACGME) and led them to establish a task force for the development of criteria for accrediting subspecialty programs and guidelines for recognizing a subspecialty. The ACGME policy statement on the accreditation of subspecialty programs appears in the Appendix attached to this editorial. Before I address the issue of subspecialization in Radiation Oncology, it is necessary to understand in greater detail the dual processes of accreditation and certification. Accreditation of institutions to offer programs in Postgraduate Medical Education and certification of the individual to practice a certain specialty of medicine are governed by a singular body in Canada and England and
Accepted
for publication
IL 60 153
I8 June 1992. 987
988
I. J. Radiation Oncology 0 Biology 0 Physics
within a particular field of medicine, gains prestige and recognition as a subspecialist from publications in the subspecialty journal and regular attendance at meetings of the national society; thus he or she strongly favors subspecialization. The trainee who is required to learn a broad area of knowledge is generally disinterested in focused expertise unless he or she plans to pursue an academic career. Patients who want a physician that cares for all of their problems are generally unhappy being passed from one subspecialist to another though it might be argued that a subspecialist is more likely to diagnose and properly treat the patient’s illness. I would tend to believe that subspecialization is most advantageous to the subspecialist, partly advantageous to the patient and advantageous to the trainee only after they have completed their broad general training and decide to subspecialize. When I joined Mallinckrodt Institute of Radiology in 1974,l became a subspecialist dealing with cancers of the upper aerodigestive tract and brain. I did clinical and some collaborative basic research, published in subspecialty journals and regularly attended the meetings of several national societies. The prestige and recognition gained as a subspecialist was most rewarding. The residents benefitted from my detailed knowledge of the literature and expertise in managing patients with head and neck cancer and brain tumors though one particular resident correctly observed that I didn’t know anything else but head and neck cancer and brain tumors. When I came to Loyola in 1985, I again became responsible for the broad spectrum of patients with cancer and had to relearn the general field of Radiation Oncology. As I worked on the Residency Review Committee reviewing programs across the United States, I became aware how important it was for residents to learn the breadth of oncology. It concerned those of us on the Committee that so many programs lacked experience in important areas and that so many faculty were not engaged in academic process. Compared to these problems, the issue of subspecialization seemed less important to me. Indeed, our specialty has developed a plethora of special fields of knowledge and areas of research; these include Pediatric Oncology, Brachytherapy, Heavy Particle Irradiation, Hyperthermia, Radiolabeled Antibodies, Intraoperative Radiotherapy, Stereotactic Radiosurgery and now High Dose Rate (HDR) Afterloading. All of the subspecialty areas within Radiation
Volume 24. Number 5. 1992
Oncology are important areas of research particularly for those faculty members involved in the advancement of that area of knowledge. But, none have developed to the extent that they might be accredited as a subspecialty by ACGME. There are too few Pediatric Radiation Oncologists to form a subspecialty of 25 or more programs similar to Pediatric Radiology or Neuroradiology. There are too few institutions with Heavy Particle Irradiation to justify accreditation of that as a subspecialty. Hyperthermia is a modality instead of a clinical field of knowledge as is Intraoperative Radiotherapy, Stereotactic Radiosurgery, Radiolabeled Antibodies and High Dose Rate Afterloading. It seems to me that Brachytherapy is the only subspecialty area that has developed sufficiently to be considered as a subspecialty within Radiation Oncology. It is generally practiced to a greater or lesser degree in all institutions; there are an increasing number radiation oncologists who are recognized for their expertise in Brachytherapy; it has its own separate Society, The American Endocurietherapy Society, and its own separate journal, the Journal of Endocurietherapy/Hyperthermia Oncology; several departments in large institutions have established separate Brachytherapy Services and more recently cooperative working groups for High Dose Rate Afterloading have been established in this country and Europe. Thus Brachytherapy more closely meets ACGME guidelines for recognition as a subspecialty than any other area within Radiation Oncology. If accreditation without certification is possible, why not certification without accreditation? It might be proposed to the American Board of Radiology to offer Certificates of Added Qualification for select subspecialty areas before they have developed sufficiently to be recognized as an accredited subspecialty of Radiation Oncology. If the subspecialty area were able to develop educational standards and had several recognized fellowships in major institutions that graduated highly trained subspecialists, then a Certificate of Added Qualifications might be justified before the development of subspecialty accreditation. Certification before accreditation might prove unacceptable to the American Board of Radiology but presently seems the only possible means of recognizing subspecialization within Radiation Oncology. The subspecialty areas within our field are presently too small and underdeveloped to qualify for accreditation by ACGME.
0360-3016192 $5.00 Copyright G 1992 Pergamon Press Ltd.
Vol.24,PP. 987-988
In1 J. Radiarm Oncoloyy RIO/. Phys Printed in the U.S.A All rights reserved.
??Editorial
SUBSPECIALIZATION
IN RADIATION
ONCOLOGY
JAMES E. MARKS, M.D. Dept. of Radiotherapy,
Loyola University
Medical Ctr., 2 160 South First Ave., Maywood,
dual bodies in the United States. The Accreditation Council for Graduate Medical Education accredits training programs in the United States and the Boards of Medical Specialties certify the individual. Those responsible for accreditation don’t necessarily act in concert with those responsible for certification. In fact, ACGME held a special conference entitled, “Accreditation Without Certification” whose purpose was to better define and coordinate the processes of accreditation and certification. The Accreditation Council for Graduate Medical Education required communication between the Residency Review Committee for the specialty and the relevant board concerning the establishment of a new subspecialty and documentation that the board would or would not award a certificate in that subspecialty. The Accreditation Council for Graduate Medical Education was willing to consider accreditation of a subspecialty even if the board opposed it provided the subspecialty met all guidelines required for subspecialty recognition. Clearly though, ACGME preferred that a board recognize a particular subspecialty and be willing to certify graduates of accredited programs. In the case of Radiology, ACGME accreditation of Pediatric Radiology, Neuroradiology, Vascular and Interventional Radiology was followed closely by a decision of the American Board of Radiology to offer Certificates of Added Qualifications in these subspecialty areas (Communication to program directors and departmental chairman from Thomas F. Meaney, M.D., President of the American Board of Radiology, 5/7/92). Thus, the processes of accreditation and certification for the new subspecialty areas of Radiology were closely coordinated by members of the Residency Review Committee and the American Board of Radiology. This was largely possible because the American Board of Radiology has several members on the Residency Review Committee and regularly participates in the accreditation process. The progressive fragmentation of medicine into more and more medical specialties is viewed differently by the patient, the trainee, and faculty member. The faculty member who is responsible for advancing knowledge
In 1972, when I was certified by the American Board of Radiology to practice the subspecialty therapeutic radiology, there were 29 separate specialties in American medicine. Today, 20 years later, there are a total of 75 separate specialties listed in the AMA Directory of Graduate Medical Education Programs. Each specialty has its own special requirements for training in that particular field of medicine. The tendency for medicine to fragment into subspecialty parts resulted from an enormous growth in medical knowledge and the recognition that a single physician could not learn all areas of medicine. Practitioners developed areas of special expertise within broad disciplines and faculty become subspecialized as they pursued their research and developed special areas of knowledge within the specialty. Internal medicine was the earliest to divide itself into subspecialty areas and served as an example for other specialties that sought to develop subspecialty training programs. Internal medicine with eleven subspecialty programs is followed by Pathology with eight, Pediatrics with seven, Orthopedics with six, Surgery with four, and Radiology with four. Radiology first recognized Nuclear Radiology and Radiation Oncology as separate subspecialties and only recently has developed separate accreditation for Pediatric Radiology, Neuroradiology, and Vascular and Interventional Radiology. The recent proliferation of so many subspecialties in medicine posed an enormous workload for the Accreditation Council for Graduate Medical Education (ACGME) and led them to establish a task force for the development of criteria for accrediting subspecialty programs and guidelines for recognizing a subspecialty. The ACGME policy statement on the accreditation of subspecialty programs appears in the Appendix attached to this editorial. Before I address the issue of subspecialization in Radiation Oncology, it is necessary to understand in greater detail the dual processes of accreditation and certification. Accreditation of institutions to offer programs in Postgraduate Medical Education and certification of the individual to practice a certain specialty of medicine are governed by a singular body in Canada and England and
Accepted
for publication
IL 60 153
I8 June 1992. 987
988
I. J. Radiation Oncology 0 Biology 0 Physics
within a particular field of medicine, gains prestige and recognition as a subspecialist from publications in the subspecialty journal and regular attendance at meetings of the national society; thus he or she strongly favors subspecialization. The trainee who is required to learn a broad area of knowledge is generally disinterested in focused expertise unless he or she plans to pursue an academic career. Patients who want a physician that cares for all of their problems are generally unhappy being passed from one subspecialist to another though it might be argued that a subspecialist is more likely to diagnose and properly treat the patient’s illness. I would tend to believe that subspecialization is most advantageous to the subspecialist, partly advantageous to the patient and advantageous to the trainee only after they have completed their broad general training and decide to subspecialize. When I joined Mallinckrodt Institute of Radiology in 1974,l became a subspecialist dealing with cancers of the upper aerodigestive tract and brain. I did clinical and some collaborative basic research, published in subspecialty journals and regularly attended the meetings of several national societies. The prestige and recognition gained as a subspecialist was most rewarding. The residents benefitted from my detailed knowledge of the literature and expertise in managing patients with head and neck cancer and brain tumors though one particular resident correctly observed that I didn’t know anything else but head and neck cancer and brain tumors. When I came to Loyola in 1985, I again became responsible for the broad spectrum of patients with cancer and had to relearn the general field of Radiation Oncology. As I worked on the Residency Review Committee reviewing programs across the United States, I became aware how important it was for residents to learn the breadth of oncology. It concerned those of us on the Committee that so many programs lacked experience in important areas and that so many faculty were not engaged in academic process. Compared to these problems, the issue of subspecialization seemed less important to me. Indeed, our specialty has developed a plethora of special fields of knowledge and areas of research; these include Pediatric Oncology, Brachytherapy, Heavy Particle Irradiation, Hyperthermia, Radiolabeled Antibodies, Intraoperative Radiotherapy, Stereotactic Radiosurgery and now High Dose Rate (HDR) Afterloading. All of the subspecialty areas within Radiation
Volume 24. Number 5. 1992
Oncology are important areas of research particularly for those faculty members involved in the advancement of that area of knowledge. But, none have developed to the extent that they might be accredited as a subspecialty by ACGME. There are too few Pediatric Radiation Oncologists to form a subspecialty of 25 or more programs similar to Pediatric Radiology or Neuroradiology. There are too few institutions with Heavy Particle Irradiation to justify accreditation of that as a subspecialty. Hyperthermia is a modality instead of a clinical field of knowledge as is Intraoperative Radiotherapy, Stereotactic Radiosurgery, Radiolabeled Antibodies and High Dose Rate Afterloading. It seems to me that Brachytherapy is the only subspecialty area that has developed sufficiently to be considered as a subspecialty within Radiation Oncology. It is generally practiced to a greater or lesser degree in all institutions; there are an increasing number radiation oncologists who are recognized for their expertise in Brachytherapy; it has its own separate Society, The American Endocurietherapy Society, and its own separate journal, the Journal of Endocurietherapy/Hyperthermia Oncology; several departments in large institutions have established separate Brachytherapy Services and more recently cooperative working groups for High Dose Rate Afterloading have been established in this country and Europe. Thus Brachytherapy more closely meets ACGME guidelines for recognition as a subspecialty than any other area within Radiation Oncology. If accreditation without certification is possible, why not certification without accreditation? It might be proposed to the American Board of Radiology to offer Certificates of Added Qualification for select subspecialty areas before they have developed sufficiently to be recognized as an accredited subspecialty of Radiation Oncology. If the subspecialty area were able to develop educational standards and had several recognized fellowships in major institutions that graduated highly trained subspecialists, then a Certificate of Added Qualifications might be justified before the development of subspecialty accreditation. Certification before accreditation might prove unacceptable to the American Board of Radiology but presently seems the only possible means of recognizing subspecialization within Radiation Oncology. The subspecialty areas within our field are presently too small and underdeveloped to qualify for accreditation by ACGME.
