Anatomic expertise is an essential foundational competency in radiation oncology, specifically for appropriate workup, staging, and treatment. Radiation oncologists are required to understand the relationship between target tissues, OAR, and how the surrounding anatomy dictates patterns of local disease spread when designing radiation therapy treatment plans
[6, 15]. Results of this study demonstrate an integrated, kinesthetic, MDT-based program enriches the traditional radiation oncology postgraduate curriculum, and provides the ability to assess learner performance across multiple competencies. Trainees’ knowledge and understanding of anatomy and radiology improved after being exposed to the intervention, thereby developing the key competency of establishing and maintaining clinical knowledge appropriate to practice. However, we observed suboptimal development of contouring competency, as indicated by the poor ability to apply core medical knowledge to the practical skill of accurate contouring.
Key technological innovations, such as the introduction of inverse treatment planning systems with IMRT have modified the daily practice of radiotherapy. Such advancements in technology demand stronger competencies such as contouring accuracy and target delineation. Gregoire et al. note that target volume selection and delineation undoubtedly represent the most dramatic change in clinical approach, as compared with the former 2D approach
. Furthermore, with evidence demonstrating variation in target delineation between expert clinicians, there is a need for specialized training that includes competencies such as anatomical knowledge and target delineation as a requirement of the radiation oncology postgraduate medical education curriculum
A survey of resident education in intensity modulated radiation therapy (IMRT) described by Malik et al. revealed that most (70%) respondents (from among 77 accredited radiation oncology residency programs) desired an increase in IMRT didactics, while 1/5 of the 86.9% respondents with hands-on IMRT experience lacked formal training in IMRT. There have since been several studies investigating educational techniques to improve target delineation among residents
. Institutions such as Duke University Medical Center have independently begun to address the need to formally integrate competency training and measure specific educational outcomes during the postgraduate clinical years
. A study from Memorial Sloan-Kettering demonstrated improved head-and-neck target delineation skills among 11 participants after didactic seminar series and hands-on practical image segmentation sessions
. Another study of 12 staff radiation oncologists demonstrated that an interactive, hands-on training session improved consistency in target delineation for cervical esophageal cancer
While our contouring results were suboptimal and not consistent with those of previous studies, this can primarily be attributed to the lack of integrated contouring teaching during seminars. The inability of participants to translate the knowledge to the competency of contouring highlights a misalignment of the teaching interventions curriculum objectives and evaluation methods. That is, despite providing an integrated, kinesthetic, MDT learning environment, no formal contouring instruction or practice was integrated into the seminar series. This shortcoming can be attributed to the restricted time frame allotted for seminars. Although significant improvement in contouring accuracy was only observed for 3 out of 20 anatomic structures, it is important to compare how factors such as density, material, and/or size could have impact on the level of difficulty for the anatomic structures. For example, (both pre and post) contouring accuracy was generally more accurate for bone and larger spaces/sinuses, while soft tissues (e.g. muscle or mucosa) generally demonstrated less accurate contouring. The results may furthermore be reflective of the evaluation parameters. That is, participants were not supervised during the contouring evaluation to ensure all questions were attempted. It was not determined whether DSC pre and/or post-test median scores of 0.000 were reflective of participants skipping the question, or as a result of not having the anatomy/radiology knowledge. The contouring results may also be reflective of the varying effort levels among participants; given that participants had the flexibility to complete this evaluative component during a two week time frame (pre and post contour evaluations were respectively conducted up to two weeks prior to and after the teaching intervention). Time of completion of the evaluation (e.g. post call versus during a designated research time) may have also influenced outcomes. Despite these shortcomings, quantitative VAS results revealed that participants felt more confident at contouring and treatment planning, and had a better understanding of anatomic structures and nodal levels.
These results should remind educators that educational interventions that incorporate sequenced didactic and kinesthetic components are more effective in developing procedural competencies than didactic sessions alone. As well, these findings should remind curriculum developers that targeted efforts towards developing each competency should be implemented. That is, it is flawed to assume that by establishing and maintaining clinical knowledge and attitudes appropriate to practice, trainees will also demonstrate proficient and appropriate use of practical skills (diagnostic and/or therapeutic). The local implication of the results and the supported literature should also prompt postgraduate radiation oncology programs with an apprenticeship-based model to increase the number of formalized hours dedicated to teaching core skills such as: anatomy, radiology, and contouring; as the former two components are alone not sufficient to improve the latter. On the basis of these findings, we plan to incorporate hands-on contouring practice in future teaching interventions.
While the small-group anatomy stations constituted the kinesthetic component of the educational intervention, and the literature acknowledges the importance of anatomy in radiation oncology, post-questionnaire VAS results indicated lower educational effectiveness scores of the anatomy didactic and prosection components as compared to other components. Investigators conducted follow up exit interviews and examined qualitative feedback to elucidate this finding. Participants expressed time constraints in the didactic component, and difficult emotions associated with cadaveric specimens which revealed identity (e.g. a face) as attributing potential factors.
The limitations of this study include confounders common to all pretest and posttest designs, including maturation effects (i.e. self-directed learners read about the subject prior to/after the seminar series), and repeated measurement effect (i.e. the pretest affects the posttest results). Moreover, the single-institution (lack of control group) small sample size can be considered a limitation (as sufficient power for statistical analysis becomes of concern), but the sample size is comparable to other radiation oncology educational interventions in the literature. Study investigators recognize the potential shortcoming of the quantitative evaluation tools that were used, which had not been previously tested for validity or reliability. Furthermore, we did not assess longer term outcomes to determine whether the teaching intervention was associated with retention. Postgraduate medical education researchers will also agree that commitment from participants is often difficult to obtain, as reflected by the small number of reports of resident educational interventions with evaluation of retention
. Finally, the very nature of educational interventions involves multiple simultaneous sequential learning methods and experiences. As such, it may prove difficult to elucidate which components of the intervention (e.g. instructional methods vs. experiences) helped to demonstrate a specific outcome. These shortcomings have been addressed and participant feedback incorporated as the initial pilot study has become regularly incorporated into the 2012-2013 oncology academic half day schedule, and into the design of a national level workshop.
Study limitations notwithstanding, most participants found that the teaching intervention was a valuable experience. The positive outcomes as well as the inadequacies of this study may inspire curriculum designers, educators, program directors, and students themselves, to consider educational models that advance beyond apprenticeship-focused learning, toward multidisciplinary formal designs with transparency of the required competencies. The integration of similar educational interventions into current apprenticeship-based programs is achievable with majority support from the department (program directors, attending physicians, and trainees), interdepartmental collaboration (e.g. radiology), and re-organization of traditional academic half-days. The results and implications of this study, coupled with the identified need for change at the postgraduate education level as identified through the literature, proposes a revision and harmonization of the core curricula for radiation oncologists, to reflect the rapid development of radiotherapy technology, and be inclusive of anatomy, radiology, and contouring instruction. Based on the results reported herein, the course has been modified and developed into a Canadian national “Anatomy and Radiology Contouring Bootcamp”, with changes including: increased length of anatomy prosection interaction, dedicated hands-on-contouring sessions with real-time feedback, and improved integration of teaching across MDT specialties. Future work will evaluate the improvements in anatomy and contouring knowledge for participants attending the bootcamp.