Meredith Giuliani is the current Chief Resident of the Radiation Oncology residency training program at the University of Toronto. She graciously agreed to sit down with Current Oncology to discuss her experiences in the field and answer questions about applying to radiation oncology residency programs.
Current Oncology: To start, I’m going to ask you the question that you will be asking all prospective radiation oncology residents: why radiation oncology?
Meredith: Radiation Oncology is a great specialty because of the breadth of opportunities it affords. It provides an opportunity to interact with patients clinically, but also to do research, patient education, and teaching for undergraduate and postgraduate students. Now is a very exciting time in Radiation Oncology with lots of novel research sparking big changes in the field over the last 10 years.
THE FUTURE OF RADIATION ONCOLOGY
CO: Can you tell us about some of those changes that you alluded to?
M: The precision with which we can deliver radiation and the ability to deliver escalated and more effective doses of radiation has improved. We have seen incorporation of PET scans into our staging and planning process and the increasing use of MRI in simulation. There are also new advanced technologies being developed with image-guided and intensity-modulated radiation.
CO: Students and 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?
M: I don’t think so. In Toronto, we have excellent technology and deliver excellent treatment to our patients. All of the major advances in radiation therapy are being adopted here in Toronto and across Canada. In a lot of cases, Canadian centres are leading the way in new technology developments.
CO: Can you give me an example of that?
M: IGRT (image guided radiation therapy), which means having online volumetric imaging on our treatment units, either in the form of cone-beam CT scans or, potentially in the future, MRI. Princess Margaret Hospital especially has been a major player in its development and in educating centres around the world about how to implement IGRT.
CO: How do you see the field changing in the next 10 years?
M: The past has really been about the incorporation of new technology and I think that will continue as we get better and more precise imaging. But the next area of development will be individualized treatment. As our understanding of biology and genomics improves, our ability to streamline treatments based on patient’s individual cancer characteristics will continue to improve.
CO: Where do you see the technology aspect moving in the future?
M: Improved imaging capabilities which will allow us to more accurately define cancer stage. New technology will allows us to better plan our radiation, more accurately define our target volumes and be able to accurately target these volumes.
CO: How do you keep on top of new developments in radiation oncology?
M: Obviously that’s challenging. Reading articles coming out of top journals and attending conferences lets you see the first snapshot of new trials that are changing practice. We are lucky in Toronto since we have people who are leading the way in some of these developments, so they can teach others before the data may be widely available. Also, many centres, including Toronto, have educational courses where we try to disseminate new knowledge for instance our courses on IMRT and IGRT.
THE PRACTICE OF RADIATION ONCOLOGY
CO: What do you think is the most interesting part of your job?
M: The most interesting part is always the interaction with patients and learning every patient’s story, how they perceive their condition, and how they make their decisions. You really learn from every case that you see.
CO: Is there anything that is particularly interesting that is specific to radiation oncology that might not be as available in other medical specialties?
M: All specialties to a degree work in teams, but I think Radiation Oncology is really defined by our need to work within a team. To deliver safe therapy, it is an effort among oncology, nursing, other members of the allied health team, and especially our collaboration with our physicists and radiation therapists. It’s a great opportunity to work and learn from other people and to provide team based care.
CO: What do you find is the most challenging part of your job? What strategies have you developed to deal with those challenges?
M: Working with patients to arrive at the decision that is best for them. Oncology is a complicated specialty and we work with very sick patients with very serious problems. Discussions are difficult — people are making high stakes decisions in very complicated areas. Working with patients to make sure that they have the information to make those decisions is very challenging.
Understanding patient motivation is important. Knowing what is important to an individual, rather than simply quoting data to people from large trials and explaining in detail the treatments, and learning what the goals of their treatment are is fundamental in joint decision making.
CO: After you entered RO, what were you most surprised by, positive or negative?
M: I mentioned how important the health care team is in Radiation Oncology, but I didn’t have a sense of how important that really is and the amount of collaboration that goes on before entering the specialty. I don’t think people who aren’t in the specialty can completely comprehend that, until they are actually trying to treat patients and see how important and involved the various team members are.
CO: Can you go into a little more detail about who those team members are and how you interact with them?
M: Our treatments are delivered day to day by a Radiation Therapists who are also involved in simulating the patients so we have a planning set with which to work. We work with the planners who generate the radiation treatment plan and the physicists who are both checking our treatment delivery machinery and the safety of our plans and determining whether or not things can be improved. We collaborate with our nurses and allied health care members trying to support patients through some very tough treatments.
There are a lot of people with different expertise and everybody has different opinions. This is good because a lot of minds work together on each patient. I don’t think you can fully appreciate how integrated we are into that system of people that are caring for patients. It’s not a solo experience to be a Radiation Oncologist.
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 your typical week as a PGY4 and chief resident?
M: A typical week involves a combination of multidisciplinary rounds and treatment quality assurance rounds, or what we call “check-film rounds,” clinics, planning, plan review, reviewing patients on treatments and occasionally call. Generally rounds begin at 8am, sometimes they are at noon or from 5-6pm. Clinics are either morning or afternoon. We usually have 4 and 5 clinics per week. The other time is spent working on plans, reviewing plans or seeing patients who are on treatment that have symptoms which need management in one of our nursing clinics. In PGY4, we usually do about 2 calls a month, but the more junior residents tend to do more call – usually 6 calls a month.
CO: Are the clinic and planning and rounds schedules similar for junior residents?
M: Yes. The junior residents sometimes spend less time with planning and more in clinic, but it’s still similar.
CO: Can you describe how residents progress within the program?
M: The first year of Radiation Oncology is generally off-service, so it’s basically a rotating internship even though it isn’t called that anymore. Residents obtain skills in internal medicine, surgery, palliative care, and other specialties that we collaborate with. It’s really an opportunity to learn about the decision making processes of these other specialties, the complications of their treatments and what patients who end up coming to Radiation Oncology afterwards have experienced. And, of course, we are learning general medicine so we can manage the side effects from our treatments.
The 2nd and 3rd year junior residents have more of a focus on learning the basics of oncology, the evidence behind what we treat and how we treat certain situations. They have less managerial responsibility, so they don’t have as much involvement in checking and approving plans. It’s about learning the basics, how to manage patients and about oncology in general.
CO: How does the call schedule compare for junior residents, seniors, and also for fellows and consultants at UofT? How often do emergent cases come in?
M: Call across the country is quite variable. Some programs cross cover with Medical Oncology. Some Radiation Oncology programs don’t have inpatients, so their call is home call related to urgent oncology issues. In Toronto, we have inpatients at both our sites (Princess Margaret Hospital and the Odette Cancer Centre at Sunnybrook Health Sciences Centre): one (OCC) is home call the other (PMH) is in-house call. Junior residents do more call than seniors: seniors do 2 a month, juniors do 6.
We are looking after inpatients and managing urgent issues like spinal-cord compressions that need treating out of hours and other issues.
At UofT, fellows have no mandatory call requirements, but they help us with the schedule when we don’t have enough residents which is very rare. The amount of call staff do is very institution-specific, since it depends on the number of staff. At OCC, the staff do 1 week at a time, and approximately 2 weeks a year. At PMH staff oncologists tend to do approximately 1 weekend every 6 months and then 1 or 2 nights per month.
CO: How are residents divided between the two sites?
M: 2nd year is at PMH, 3rd year is at OCC and 4th and 5th are split at the residents discretion.
RESIDENT SELECTION PROCESS
CO: Can you describe how you have been involved in the resident selection process in the past?
M: I am currently the Chief Resident, but when I was in 3rd year I was the Senior Resident and I was on our CaRMS panel last year.
CO: Can you describe how the CaRMS selection process works at UofT?
M: The residents aren’t involved in the first part of the process, when the applicants submit their written forms. There are set criteria, the submissions are marked and a threshold is set to determine who receives an interview. Interviews are generally 30 minutes in length, and you are interviewed in one of two rooms with a panel. The number of people on the panel varies, but generally 3-5 with one being a resident, either the Senior Resident (from Sunnybrook) or the Chief Resident.
Every year it varies, but there is always one of the educational program directors in the room. Dr. Millar (the Program Director) is in one room, and Dr. Ackerman, who is the program director at OCC is in another. Other faculty members who are involved in the postgraduate committee or education also sit on the panel.
CO: What qualities are most important for you to see when choosing a resident? How can an applicant demonstrate these qualities to you?
M: Somebody who is inquisitive and likes to learn and is able to work as a team. The ability to work with others is very important.
Past experience, things you have done through work or in medical school or other activities are informative.
CO: Are there qualities that you look for specific to radiation oncology itself as distinct from other specialties?
M: We can dispel a myth. I think people think that a math and physics background is critical to applying to Radiation Oncology and a resident will struggle without that background. It is a very integral part of what we do, but as long as people can learn and are interested and willing to learn those concepts, you don’t have to have a strong background. Our most engaged people come from diverse backgrounds. Understanding physics and math is integral to what we do, but I don’t think you absolutely have to have a strong background in it – you just need to be willing to learn.
CO: How does someone show that they are suitable to be selected by your program?
M: An interest in research and an understanding of the labour intensity and the effort that goes into producing quality research is important. Somebody who is able to learn concepts that are from a broad range of science, since our specialty covers everything from basic physics to genomics and molecular biology.
I already said working in teams is important but we like to see the ability to function in a big centre, since Radiation Oncology is conducted in cancer centres. It’s not a specialty where you own your own practice. Therefore it’s a very different from someone who owns their own practice and can work anywhere. Those are some of the big facets.
It’s a fascinating specialty because of the diversity and there is a lot of room for people from all different backgrounds. I don’t think there is one cookie cutter profile, either on paper or in person which shows “that person’s a Radiation Oncologist.” I think a combination of personality traits –curiosity and the desire to deliver high quality patient care and work in a high stakes specialty are important.
I think it’s important for people to understand that we are looking for diversity. I think people have an impression that we are looking for a specific type of person, but that’s not true either in Toronto or across the country.
CO: You mentioned research as important. Does that research need to be radiation oncology specific or will rigorous, but non-radiation-oncology-related, research be regarded similarly?
M: We are interested in research that spans the spectrum. We’ve had residents with very successful collaborations with other departments. Part of our department’s strategic vision is that to move forward, we need to work with different disciplines on novel approaches and research that is focused on the specialty and in other areas are both valued.
CO: Can you talk about how the interview is weighted and scored?
M: There is a standardized set of questions and all interview panel members score the applicants. The interview scores and CaRMS application are summed to obtain a final score.
My understanding is that the interview process is very diverse across the country. Some places have multiple rooms asking different questions in each room, some places have very big panels in only one room.
CO: You are a PGY4 getting toward the end of residency and, I’m sure, starting to think about life beyond residency. What is your impression of how life as a staff radiation oncologist differs from that of a resident?
M: As a staff, the buck stops with you. You are responsible for following everything that is going on with every patient, and sometimes covering other staff’s patients. Certainly, in our department, we have a very collegial group of staff. Morale and academic stimulation is high.
CO: How does the weekly schedule of a staff differ from your schedule as a senior resident?
M: It’s largely the same – roughly the same number of clinics, they also go to the same rounds. They do have other duties like site-specific business meetings, research commitments, and committees. The volume of clinics and the number of sites a staff treats varies depending on whether they are a full clinician or a clinician-scientist, and how much research or education time they have been allocated.
CO: For a full clinician, how many clinics per week would they be doing?
M: It is generally between 6 and 8. Some are planning clinics and review clinics, but the rest of the time would be for planning and other activities.
CO: How does planning clinic differ from planning time?
M: Some people have simulation clinics where they are present when the patients are being simulated at the CT scanners. Planning time is actually doing the plans, delineating your targets, and reviewing plans with the physicists and therapists about plan optimization and whether it is safe and meeting objectives.
CO: People often hear that the job situation in radiation oncology, especially in Canada, is difficult for new graduates. You must be thinking about what the future holds and have spoken to newly graduated peers. What is your opinion on that statement?
M: The reality, especially in academic practice, is that people are going to do fellowships to subspecialize either in a novel clinical site or to develop research expertise. However, some graduates from our program who are working in regional centres have gone straight into practice from residency. We also have graduates taking time as fellows to complete graduate degrees, and get a stronger background in research because that’s where they want their career to go. We’ve had people move internationally to practice, people have stayed in our centres or affiliated regional centres and people who have moved to various parts of the country. There are a lot of different options reflecting what people do when they are finished residency .
CO: Is there a perception that a fellowship is necessary to work in a desirable location?
M: That depends on what you consider to be a desirable location. To work in an academic centre, people need fellowships and that will continue to be the case.
CO: Is it possible to work in a large metropolitan area without working in an academic centre in Canada?
M: A lot of the radiation oncology centres are in major hospitals. But you can live in a major metro area without working in academia and having a big research practice. Some of our recent graduates who work at some of our regional centres still live in Toronto.
CO: Can you tell us where some of those centres are?
M: The one that comes to mind is Southlake (in Newmarket, Ontario). We have recent graduates who work there and live in Toronto.
CO: What qualifications are needed to get into a fellowship training program?
M: There are different types of fellowships. There are clinical fellowships and there are research fellowships. If you are going into one of the graduate degree fellowships, you need to meet the entrance criteria of that graduate program.
With clinical fellowships, it’s about demonstrating your interest in that site and, if you are moving outside of your residency centre, reference letters from people that you worked with are important. If you are entering a research fellowship, then demonstrating that you have had experience with research is important. This can be demonstrated in part by previous publications.
CO: Do you think clinical and research fellowships are deemed as equivalent additional qualifications for job applications?
M: Yes. It depends on the job for which you are applying and what the centre that is hiring you is looking for. Centres have different needs at different times. What different centres are looking for at different times is very variable. Finding something that you are interested in and like to do is most important.
CO: Bottom line: Are you worried about finding a job?
M: I’m not worried, but I think there are realities with Radiation Oncology that people need to be aware of. We practice in big centres and you can’t just set up your own practice. You have to understand that you are going into a specialty where there are certain centres that have radiation bunkers and there are only certain places where you can live. There are lots of places in the country that have radiation centres but it’s not the same as other specialties where you are extremely flexible.
CO: Radiation Oncology seems very academic – there are many projects and clinical trials going on all the time. Do you think research is a requirement for a career and for residency?
M: I don’t think it’s a requirement for being a staff. Most Radiation Oncologists hired across Canada are hired as clinicians. However, in Toronto, at both centres, we have a high proportion of clinician-scientists and clinician-educators who do research, and there are other centres that are like that as well.
In terms of residency, all programs are different and set their own expectations. In Toronto, the expectation is that you will participate in one project, and it’s usually a great learning opportunity. Programs vary in the minimum requirement, but research is not mandatory to practice Radiation Oncology.
CO: What salary range can a new radiation oncology expect to make in Canada? Is there a difference between academic and community practice?
M: It varies with where you work, and it’s something you need to explore with the centre to which you are applying. In Ontario, there is a base salary and fee-for-service billing on top of that, but how it works is different based on the centre.
CO: What do you think are the most important skills for a resident to develop to become an effective staff radiation oncologist?
M: Other than the medical expertise, understanding what your colleagues are bringing to the table and what their roles are is very important. Having a strategy to understand new technology, knowing how you learn best and how to keep up to date on new data when you are in practice.
The great opportunity in residency is to understand what you want out of a practice. What is it that you enjoy doing every day and how do you want your practice to look. The great thing as a resident is you can explore what you enjoy and can find a model of practice that is going to be satisfactory to you.
CO: Thank you very much, Meredith. I think our readers will find our discussion insightful and helpful.