Current Oncology: This is an interview with Dr. Barbara-Ann Millar, staff oncologist at Princess Margaret Hospital and the Hospital for Sick Children in Toronto and the current Program Director of the University of Toronto Radiation Oncology residency program. She has agreed to sit down with Current Oncology to discuss issues relating to radiation oncology in Toronto and elsewhere. First of all thank you for agreeing to speak with me today.
First off, I’m going to ask you a question that you will be asking all prospective radiation oncology residents which is: why radiation oncology?
Dr. Barbara-Ann Millar: Radiation oncology is a specialty that has many facets that keep you wanting to come back to work and engage you in lots of different ways. When lots of people think about radiation oncology, they think it’s a terribly technical specialty. It does have technical aspects but there is also a huge clinical component and the combination of those two is very engaging. We are very fortunate to work within a multidisciplinary team with input from different colleagues including medical and surgical oncologists, as well as colleagues in physics, radiation therapy and nursing, and that allows you to work in a collaborative environment which is very enjoyable to be around.
Also, we are a very innovative specialty. Radiation oncology has changed dramatically within the last 15-20 years, and we’re now able to better treat our patients, reduce the toxicity of treatments, and are very collaborative with the other specialties to deliver combined-modality treatment. These are all very interesting developments and it’s a very forward moving specialty.
THE FUTURE OF RADIATION ONCOLOGY
CO: Can you be more specific about some of the innovations you have seen over your career and where you expect to see the field going in the next 10 years?
BAM: One of the most interesting developments is our ability to guide the radiation therapy much more accurately. That utilizes different diagnostic modalities like cone-beam imaging both to delineate where we want to target and to double check where we are treating when the patient is on the treatment unit. IMRT (intensity-modulated radiation therapy) has been a huge advancement, particularly in my practice specializing in pediatric radiation oncology. The ability for us to deliver very high dose radiation but spare critical structures much more effectively has really been a tremendous improvement in our ability to deliver radiation therapy, as has the accuracy at which we know we can deliver that because of the online imaging on our treatment units.
I think that diagnostic imaging will continue to keep pace with its research and allow us to even more clearly delineate what our actual targets should be for active disease and potential sites of disease, and allow us to continue to modify what we are having to treat and what we can spare to reduce toxicity and increase the therapeutic ratio so that we can actually get more curative treatment with decreased toxicity.
CO: Since radiation oncology is a rapidly developing field, do you have strategies to help you keep on top of new developments?
BAM: At Uof T we are fortunate to have a strong ongoing continuing medical education system with ongoing rounds and courses. That allows us to keep abreast of what’s being innovated in other disease sites, because you tend to become somewhat focused on your small, personal sites. We have our weekly rounds both here and at Odette (the cancer centre at Sunnybrook Health Sciences Centre) which include other disciplines, like physics. We also invite different speakers and visiting professors to speak, so we hear about how the profession is developing. And we are also well supported to attend national and international meetings and are encouraged to present our own research at those forums, so that allows us to find out what’s happening on an international basis.
CO: Students and new residents often hear that, especially in Canada, new technology is slow to be adopted compared to other places like the US. Do you think that is a problem in radiation oncology?
BAM: I think that has been an issue, but we are fortunate to have had a leadership that has seen where the specialty is moving over the next 20 years and have integrated new modes of treatment and new technology very readily. I think that has been the majority of the cases across Canada. There has been a huge buy-in to improving technical delivery of radiation oncology. We are very fortunate in Canada to have a lot of the resources we have — if you look at some areas in Europe, high end radiation delivery is not as accessible as we have here. In fact, the bigger Canadian centres are very engaged in doing beta testing and giving feedback to industry to say “this is what we actually want to be able to do for our patients to enable us to treat them better.”
THE PRACTICE OF RADIATION ONCOLOGY
CO: What do you think is the most interesting part of your job?
BAM: I’m lucky in that I have lots of interesting parts of my job. I very much enjoy my clinical work; I have a very interesting practice. Even though I cannot cure some of the patients I treat, I know that I can significantly improve their quality of life. And some of the patients I can cure and hopefully get to follow them much later on in their life, as in my pediatric practice, when they transfer at 18 from Sick Kids. So I think that’s one of the very nice aspects of my job.
I really also enjoy being a program director, I think it’s a great position to be able to influence and, hopefully, structure a program which gives people a really sound basis for their ongoing career. Because it really is an ongoing career, it’s an ongoing learning process. And it’s very useful to be able to meet up later with people who trained in the program and see where there careers have gone. I think that’s a very nice position to be in.
CO: Is there anything that is particularly interesting that is specific to radiation oncology that might not be as available in other medical specialties?
BAM: That comes down to the technical aspect plus the clinical aspect of radiation oncology. I think a lot of people aren’t aware of this — they think radiation oncology is a bit like diagnostic imaging with looking at images or firing X-ray beams at targets. They don’t realize that while there’s a planning component and very technical aspects to treatment delivery, there is also a very clinical, multidisciplinary, collaborative aspect around designing appropriate treatment for patients and ongoing assessment and involvement with those patients long-term.
CO: What do you find is the most challenging part of your job?
BAM: There are days when things are not going well such as when patients you have been following have their disease progress and you are in a position where there is not much else you can do. I think everyone finds that a challenging part of their work. Unlike other disciplines, people ask me how I can do pediatrics and I say “I don’t give people this diagnosis, they came with that diagnosis.” We are hopefully in a position where we can do something to help them. I think that is a good mantra, that you are trying to be there to be helpful to people and improve their situation and you know that you aren’t always in a position to take this away or cure it. But you are in a position where you can give quality time and improve patients’ quality of life. But we do cure them as well, of course.
Challenges arise with people who you’ve worked with for a long time, done multiple interventions for them and they’ve improved and then you get to the end of the line and there isn’t much else you can do.
CO: After you entered radiation oncology, what were you most surprised by, positive or negative?
BAM: Because I trained in the United Kingdom, I was actually trained in radiation and chemotherapy as a clinical oncologist. When I came into oncology generally, I was most impressed by the number of patients you could cure with radiation alone. I did one of my first rotations in head and neck practice, and I’d be following patients who had been treated 5 or 10 years prior purely with radiation. I think as a med student you aren’t aware of radiation as a curative modality as much as, say, surgery. That’s always very impressive. And I think what’s really impressive is cure and the reduction in the toxicities with which radiation can be delivered improving peoples’ quality of life as well as curing their disease.
CO: Is there anything you were surprised by that disappointed you?
BAM: What always disappoints me is when patients are referred very late; when other physicians don’t recognize that radiation is an extremely helpful modality for patients not just for curative treatment but also for palliation. It’s always very disappointing when patients present much more debilitated or affected by the disease than they need to be.
LIFE AS A RADIATION ONCOLOGIST
CO: I’m now going to ask you some questions related to residency in radiation oncology. First of all, can you describe the typical week of a resident in your program?
BAM: The early stage residents – the PGY1’s – are getting clinical experience in general medicine, surgery, ER, pediatrics, and other specialties. They work in teams, on the wards, looking after inpatients, dealing with emergency new patients, and on call at night. Then we have an academic block [for the PGY1’s] which has academic teaching about physics, radiobiology, intro to clinical oncology, and other topics.
Second year is more oncology based with some more team medicine. That gives residents more of a flavour of other specialties including medical oncology and some radiation oncology as well.
Years 3-5 is radiation oncology only. So your normal week would be working with 1 or 2 staff member – you would do their clinics, you would be attached to their planning sessions, you go to their tumour boards and quality assurance rounds, stay involved with looking after patients on the inpatient floor and take call.
CO: How does life as a staff radiation oncologist differ from that of a resident?
BAM: You suddenly realize that the buck stops with you and you are the ultimately responsible individual. When you start as a staff, it is quite overwhelming to begin with. As a resident, you should absolutely maximize your time of not being that person to gain as much experience as you can, but towards the end of your residency start thinking, “what would I do in that position?” to allow you to transition to a staff role in a much more confident manner. It’s not until you take away that staff person supervising you and say “they aren’t here, I have to make decisions” and develop a strategy for how you would do that that you can really make the transition.
CO: On a more concrete level, are there differences between the weekly schedule of a staff and a resident?
BAM: Much longer hours for staff. We have a lot of commitments that don’t appear on our actual schedules like committee meetings, signing off on things both on the electronic system and letters, replying to emails, talking to patients and other colleagues. Our days are quite long, very full, and very busy. And I think one thing you learn quickly is to adapt to the situation you find yourself in.
CO: Do you think staff RO workload and hours are comparable to other specialties?
BAM: Depends which specialty. I chose radiation oncology for lots of reasons. One of the reasons is I like being busy during the day and I don’t mind working a long day. Our on-call is very manageable and because we work in a big partnership, not very frequent.
RESIDENT SELECTION PROCESS
CO: Can you describe how the CaRMS selection process works at U of T?
BAM: We have set criteria on which the applicants are all assessed looking at their academic record, their research, their interests, their background academically, their personal letters. These factors are scored and there is a cutoff of the top scorers whom we invite to interview.
CO: Can you comment on how the interview is weighted and scored?
BAM: As a program, we derive a question scheme and all candidates are asked the same questions by the interview panel and then scored. We tally up the scores and decide who is best and who we actually want to shortlist for CaRMS.
CO: What qualities are most important for you to see when choosing a resident?
BAM: Someone who has a real interest in oncology specifically, and radiation oncology more specifically. I would like to know that they actually understand what is involved in our specialty, hopefully through an elective. They should have a real enthusiasm for the subject and a real interest in what they are doing. I would like them to have a keen interest in their clinical work and their enthusiasm toward patients. An inquiring mind is also a really good thing to have. People who say “how do we do that?” and really want to know more. That’s always a very positive thing.
CO: You mentioned electives, but are there other ways that an applicant can demonstrate that they have those qualities you are looking for?
BAM: Electives are certainly one way. I know that a number of residents have had exposure through either volunteering in hospitals or some people have had personal experiences where they have interacted with RO. I think electives are the best way to get a clear insight into what a specialty involves; sometimes an elective is not available so a short period shadowing someone is something that we would sometimes consider. But an elective is the best way to experience all the areas that are involved in RO.
CO: Are there qualities that you look for that are specific to radiation oncology as distinct from other specialties?
BAM: Probably not. We’re not looking for anyone to have a PhD in physics. We are looking for people who are academically very smart with very good people skills. People who can interact in a very collaborative environment, people who can get along with others and work effectively in a collaborative, team environment. Because it’s not silos here, you have to be able to work with all members of the team. We also want people who are enthusiastic and who think outside the box.
CO: How important is research? Does that research need to be radiation oncology specific or will rigorous, but non-radiation oncology based, work be regarded similarly?
BAM: Coming into radiation oncology, we like people who have had a research interest. If they have been able to present or publish on their work, that’s great – that shows us they actually understand the process, but it’s not essential. Oncology-based work is also not essential, but it does show that you understand the different ways in which oncology works. The work doesn’t have to be specific to radiation oncology, but research within the oncological sphere, like in molecular biology or bioengineering, tells us that you understand oncology and how it works.
CO: People often hear that the job situation in radiation oncology, especially in Canada, is difficult for new graduates. What is your opinion on that statement?
BAM: Keep in mind that there are a number of different specialties in Canada where there are concerns about jobs. I think radiation oncology has had this hanging over its head for 20 years now, and there was a time when it was a concern and people did have to go away to work.
I think the current projections on expansion of units within Ontario are hopeful. However, the ability to take up position exactly where one wants at a specific point in time is probably challenging, you may have to look more broadly to find a job initially and then perhaps get your next job where you want to be. I think there will be job positions – there are new positions coming and in the next 5, 10, 15 years there will be a large number of people who will step out of radiation oncology.
We are working in a very large population which is getting progressively older so the requirements for cancer services are only going to increase. So I don’t think we’ll be out of a job any time soon.
CO: Can you comment on some experiences that recent grads have had in looking for jobs?
BAM: Recent grads here often undertake a fellowship to gain specific skills. In the past few years, people have gone to do fellowships in other countries as well as in Canada. Some have gone on to work where they did their fellowship – one grad did a fellowship in brachytherapy and gynecologic oncology in Vienna and is now on staff in Vienna. We have others who have gone to do fellowships abroad in the US and have come back to take faculty positions here.
With the opening of new cancer centres, we have seen graduates who have done fellowships and gone to work at those centres and a couple who have even gone straight from residency into a position at a new centre.
CO: Is there a perception that a fellowship is necessary to work in a desirable location?
BAM: I think the fellowship gives you the advantage of acquiring a specific skill set that a specific centre needs. Particularly if you are looking to work at an academic centre, you certainly want to show that you can be academically productive.
CO: Is it possible to work in a large metropolitan area without working a fellowship?
BAM: That depends on the individual and how productive they had been during their residency and what skills they had gained. If someone had been extremely productive academically – writing grants, doing research, publishing and possessed a specific skill set that we needed, perhaps we would hire them. However, most academic centres see the value in having a fellowship, even if just to increase your knowledge base.
CO: Is it possible to work in a large metro area without working in an academic centre?
BAM: Absolutely. With the development of the newer centres in the larger Toronto area, people have gone to work there without a fellowship. But, if they are looking for specific skills, or if a candidate feels that they would like to enhance their skills in a specific area before entering a staff position, then fellowship training would be appropriate.
CO: What qualifications are needed to get into a fellowship training program?
BAM: It’s good to have an idea of why you want to do a fellowship and what skills do you see yourself acquiring to take into your career. They aren’t looking for specific qualifications – they want to see that you have an idea of why you want to do the fellowship and that you are enthusiastic. It might help, perhaps, to have done some work in that specific area perhaps to show a definite interest.
CO: It seems like medicine is a career where you are expected to choose without knowing much about jobs, lifestyle and, in particular, salary expectations. Can you comment on salary expectations in radiation oncology?
BAM: I don’t know that I’m the best person to comment. I don’t know what the salaries are across the different specialties. Even within radiation oncology there is a huge variation in people’s salaries depending on whether they work within a partnership, whether they work as independent practitioners, or in a group practice as most radiation oncologists do. The way that remuneration happens is different depending on which centre you work at. I think that’s difficult for me to comment on.
CO: Radiation oncology seems very academic and there are many projects and clinical trials going on all the time. Is research is a requirement for residency and for a career?
BAM: Our mandate at U of T is to develop the leaders of the future. It would be a mistake to say that we are not interested in research in people who come into the program. People don’t have to have published, but to show engagement and enthusiasm in the research process is important.
We need research in all its different forms, not just phase III clinical studies. We need all sorts of innovation and inquiry to move our profession forward. And I think that’s one of our great strengths in radiation oncology, that there is an enthusiasm to move the profession forward by doing research. Certainly our residents are very strongly encouraged to be involved in different research projects but finding one that you feel engaged with and enthusiastic about will help you move forward.
As staff, we are involved in all areas of research. Some of us do very basic lab research – the clinician-scientists. Some are in translation research, some in clinical trials, studies with new drugs, new treatment techniques, educational research, and other different areas. Some people seem to have a very strict idea of what research is, but really it involves any creative professional activity which we are all involved in to some extent.
CO: Is there any focus on research at the centres around Toronto other than Sunnybrook and PMH, the Toronto teaching hospitals?
BAM: Yes. A lot of those centres are involved in clinical trials and have strong participation in these areas. These centres have developed specific focuses, and are involved in research as well.
CO: Finally, what do you think are the most important skills for a resident to develop to become an effective staff RO?
BAM: The most important skills are: 1) take responsibility, 2) assume the buck ends with you, and 3) a bit of obsessive compulsiveness, which is not a bad thing to ensure that everything is finished off.
The thing about radiation is you can’t take it back, we have no antidote. So if you are going to deliver radiation therapy, be sure that you are absolutely confident that that is what you want to do and that your plan is exactly what you want to deliver. So a bit of OCD is a good thing.
It is important to see as many cases as you can as a resident and gain as much exposure to as many different clinical cases that you can. And just have an inquiring mind. Don’t just assume that because someone told you to do something one way that that’s the right way. Think about it, read around it, be inquiring.
CO: Thank you very much for speaking to us today.