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United States Radiation Oncology Curriculum Development: The Tail is Wagging the
Dog

Daniel W. Golden, MD MHPE

PII: S0360-3016(19)34458-X
DOI: https://doi.org/10.1016/j.ijrobp.2019.11.399
Reference: ROB 26078

To appear in: International Journal of Radiation Oncology • Biology • Physics

Please cite this article as: Golden DW, United States Radiation Oncology Curriculum Development: The
Tail is Wagging the Dog, International Journal of Radiation Oncology • Biology • Physics (2019), doi:
https://doi.org/10.1016/j.ijrobp.2019.11.399.

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Title: United States Radiation Oncology Curriculum Development: The Tail is Wagging the Dog

Authors: Daniel W. Golden MD MHPE1*

1
Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL, USA

*Corresponding author:
Daniel W. Golden, MD MHPE
Department of Radiation and Cellular Oncology
Pritzker School of Medicine
University of Chicago
5758 South Maryland Avenue MC 9006
Chicago, IL 60637
Phone (773) 702-6870
Fax (773) 834-7340
Email: dgolden@radonc.uchicago.edu

Running Title: United States Curriculum Development

Funding: none

Acknowledgements: The author is grateful for the critical review and feedback on drafts of this
manuscript by Robert Amdur, Ritu Arya, Steve Braunstein, Jeffrey Brower, Erin Gillespie,
Chelain Goodman, Jillian Gunther, W. Robert Lee, Kenneth Olivier, Rahul Tendulkar, Charles
Thomas, Gayle Woloschack, and Elaine Zeman.

Conflicts of interest: Dr. Golden reports a financial interest in RadOncQuestions, LLC and
HemOncReview LLC. Dr. Golden has received grant funding from the Radiologic Society of
North America, Bucksbaum Institute for Clinical Excellence, Radiation Oncology Institute, and
National Institutes of Health.

Key Words: radiation oncology, graduate medical education, curriculum development

United States Radiation Oncology Curriculum Development: The Tail is Wagging the Dog

The current United States graduate medical education (GME) radiation oncology

curriculum lacks clarity and focus. This is evidenced by the fact that radiation oncology

residents and educators are struggling to determine what content they need to study and teach,

respectively. Currently available materials from the American Board of Radiology (ABR),

Accreditation Committee for Graduate Medical Education (ACGME), and American Society for

Radiation Oncology (ASTRO) provide limited guidance on the content to include in clinical

training programs. Residents rely on vague ABR study guides to provide guidance on what to

study. However, specialty certifying exams, as summative assessment tools, should be the final

step in a holistic curriculum development process, not the driving force of a curriculum. These

exams should be developed to assess knowledge gained through participating in a constantly

renewed training curriculum. Currently, United States GME radiation oncology curriculum

development is a case of the tail wagging the dog with United States radiation oncology

residency programs and residents using ABR exams to piece together a curriculum. This

commentary discusses two examples of how, without proactive curriculum development, the

United States GME radiation oncology curriculum is susceptible to errant changes and then

suggests a path forward to ensure a national GME radiation oncology curriculum drives ABR

exam content, rather than the other way around.

In his seminal paper, “Diseases of the Curriculum,” Abrahamson describes nine common

afflictions of medical education curricula: Curriculosclerosis, Carcinoma of the Curriculum,

Curriculoarthritis, Curriculum Disesthesia, Iatrogenic Curriculitis, Curriculum Hypertrophy,

Idiopathic Curriculitis, Intercurrent Curriculitis, and Curriculum Ossification.1 Although these

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“diseases” have varying effects on the curriculum, Abrahamson suggests that they may share a

common pathogenesis of allowing a dynamic curriculum to evolve without proactive and

structured curriculum renewal efforts. Radiation oncology in the United States does not have a

national curriculum committee responsible for maintaining and reviewing the national

curriculum. Thus, we are at high risk of developing Abrahamson’s “diseases” of the curriculum

while allowing the certifying exams to drive the curriculum discussion. Two examples of

diseases of the curriculum can be used to illustrate this very real risk.

The first disease that the radiation oncology curriculum is particularly susceptible to is

Curriculum Hypertrophy, also known as Curriculomegaly. Abrahamson describes this curricular

affliction as occurring when “…each frontier of knowledge is pushed back, each discipline tends

to want to include the new discoveries in the curriculum – but not at the expense of what that

discipline already includes.”1 With the rapidly expanding literature base and evolving treatment

delivery methods in radiation oncology it is imperative for those setting the radiation oncology

clinical curriculum to carefully consider what new content and clinical skills are being added to

the knowledge base that trainees are expected to acquire. Addition of new content will require

balanced and fair removal of outdated or irrelevant historical curricular content. Examples

include the rise of CT-based target volume delineation and the decreasing reliance on the art of

“drawing a block” over the past three decades. Similarly, radiation oncology educators must

evaluate which randomized trials remain relevant to today’s clinical practice and standards of

care and which trials should fade into the historical literature. Fortunately, much of this occurs

by necessity and attrition as teaching faculty focus on relevant clinical knowledge or skills. The

antidote to this curricular disease is constantly asking “Is this relevant to the current standard of

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care?” Educators leading residency programs, developing curriculum guides, or writing exam

items should keep this question at the front of their minds.

The second disease of concern is Carcinoma of the Curriculum. Abrahamson

characterizes this disease as the “…seemingly uncontrollable growth of one segment or

component of the curriculum.” Somewhat ominously, he continues, “in its early stages,

[carcinoma of the curriculum] is almost undetectable.” The recent release of the ABR’s

Radiation and Cancer Biology study guide,2 is an example of how, without a national curriculum

development process in place, radiation oncology is at risk of developing a carcinoma of the

curriculum. The revised radiation and cancer biology study guide recommends the addition of

Weinberg’s “The Biology of Cancer”3 to its list of resources for residents studying for the initial

certification exams, an 876-page textbook on cancer biology commonly read by PhD candidates

in cancer biology. The study guide also includes two traditional radiobiology textbooks. This

study guide, which represents a “curriculum,” was developed without using appropriate

curriculum development methodology.4,5

This is not to say that radiation and cancer biology does not represent an important

component of the overall radiation oncology curriculum. Indeed, with the new treatment

paradigms emerging with the advent of stereotactic body radiotherapy, hypofractionation,

immuno-oncology, targeted biologic agents, and numerous other therapeutic advances driven by

basic science research in radiation and cancer biology, it is imperative that radiation oncology

trainees graduate with a clinically-relevant understanding of the science behind these evolving

treatment paradigms. However, as articulated by the American College of Graduate Medical

Education (ACGME) Radiation Oncology Common Program Requirements, the primary goal of

residency is “…assuring each resident’s development of the skills, knowledge, and attitudes

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required to enter the unsupervised practice of medicine.”6 Therefore, the response to a higher

than expected failure rate on the radiation and cancer biology board exam needs to include a

holistic evaluation of the radiation oncology training curriculum, not just a revised study guide

from a small group of stakeholders regarding the specific knowledge residents are expected to

master. The hours future residents spend reading Weinberg’s “The Biology of Cancer” may

compromise their ability to study other aspects of the radiation oncology training curriculum,

perhaps most importantly, learning to competently and safely utilize radiotherapy as a

therapeutic modality for patients with cancer.

To ensure United States radiation oncology GME does not succumb to one of the

diseases of the curriculum, careful attention must be paid to the overall radiation oncology GME

curriculum. Although traditional residency training is divided by disease site, residents are

constantly learning and refining common clinical skills necessary to provide care throughout the

radiation oncology care path. A new conceptual framework for radiation oncology education is

centered around a patient’s clinical care path (Figure 1)7 as opposed to the traditional “disease

site” framework used by the ACGME for Milestones8 and the ABR for board exam breakdowns.

Knowledge that should accompany the clinical care path includes, but is not limited to, research

methodology, biostatistics, radiation and cancer biology, and radiation physics. Holistic

curriculum development methods must be applied to ensure development of a comprehensive

and complete curriculum.

There are three basic models of curriculum development, also known as “curriculum

inquiry.” Systematic curriculum inquiry is the most commonly utilized method and has been

described in the literature for over 60 years.4 The second model, deliberative curriculum inquiry

focuses on the process of curriculum planning, implementation, and evaluation and includes

4
curriculum stakeholders including the educators, learners, administration, and others that may be

impacted by the curriculum.5 Lastly, reconceptualist curriculum inquiry explores how a

curriculum relates to society.5 These three modes of curriculum inquiry are not mutually

exclusive. In fact, medical educators should ensure they utilize all three modes of inquiry,

though not necessarily equally, when developing or revising a curriculum.

When considering these curriculum development models, it becomes apparent that the

current United States radiation oncology curriculum is not being maintained with rigorous

curriculum inquiry. Stakeholders that must be involved in any revision of the radiation oncology

curriculum include residency program directors, resident physicians, radiation/cancer biologists,

and medical physicists. Other less obvious stakeholders include the most prevalent diplomates

of the ABR – radiation oncologists in private practice. This group of practicing radiation

oncologists has perhaps the best grasp of what knowledge is clinically relevant for a practicing

radiation oncologist.

Due to the lack of rigorous curriculum inquiry, the United States GME radiation

oncology curriculum is at risk of developing one or more of Abrahamson’s diseases. With

appropriate national curriculum inquiry, we can prevent this from occurring. Although the ABR

has previously stated, “Curriculum development is outside the scope of the ABR’s mission,”9

this does not need to be the case. The ABR sets the content for the initial certification

examinations that determines if a graduating resident can safely enter independent practice. The

ACGME also sets a curriculum through the common program requirements and Milestones.6,8

Lastly, ASTRO workgroups create curricula for training programs.10 Abrahamson states,

“…those responsible for [a curriculum’s] administration have the obligation to provide

intelligent, informed management.”1 Therefore, the ABR, ACGME, and ASTRO must use their

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resources to establish a holistic United States radiation oncology curriculum working group

modeled on sound principles of systematic, deliberative, and reconceptualist curriculum inquiry.

Other radiation oncology certifying organizations have accomplished this

internationally.11,12 It is important to note the difference between the recent efforts by the United

States to convene a small group of stakeholders focusing on narrow aspects of the curriculum,2,10

versus the international efforts that include stakeholders from multiple groups with an

overarching focus on the overall radiation oncology curriculum. This contrast between United

States and international radiation oncology training and certification was recently discussed in

relation to the initial certification process13 and the ABR has stated that collaboration is the way

forward.14 Other specialty societies have developed in-depth curricula for trainees.15,16 As the

premier national society for United States radiation oncology, ASTRO has the stability to ensure

this curriculum renewal process continues in perpetuity.

Through collaboration of these national stakeholder groups (ABR, ACGME, and

ASTRO), a national United States curriculum for radiation oncology must be developed to then

guide the content the ABR includes on certifying exams. An initial task of this working group

will be to develop a comprehensive curriculum map17 for radiation oncology which can then be

used to guide focused curriculum development, training program structure, and ABR exam

content. To rise to the level of our colleagues in other specialties within the United States and

our radiation oncology colleagues outside the United States, this proposed radiation oncology

curriculum working group will need to include invested stakeholders representing diverse

interests and expertise in both medical education and radiation oncology.

A United States radiation oncology curriculum working group will have a difficult task.

Members of the working group must represent a diverse cadre of professions including clinical

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radiation oncologists (academic and private practice), medical physicists, radiation and cancer

biologists, biostatisticians, bioethicists, nurses, patient/caregiver representatives, and other

stakeholders that may become apparent during the formation of such a working group.

Additionally, resident physicians must be included to ensure they have a voice in the holistic

curriculum development process. The working group would then be tasked with the challenging,

but not insurmountable, task of developing a holistic radiation oncology curriculum modeled

both on the traditional disease site conceptual framework8 and the patient care-path conceptual

framework.7 Implementation of this working group will help to prevent diseases of the radiation

oncology curriculum afflicting United States radiation oncology GME. Finally, this working

group process must be repeated on a regular basis every 5 years with smaller scale annual

reviews. A curriculum must be constantly reevaluated to account for changes in what knowledge

and skills are required to practice as competent radiation oncologist. This is similar to the plan-

do-study-act (PDSA) cycles that are used to improve quality in healthcare.18 The resulting

curriculum can then be used by the ABR to guide exam content and produce a test map that can

be used by trainees to guide their studies as they prepare for certifying exams. The American

Board of Internal Medicine (ABIM) publicly releases test maps for all of its certifying exams

which are then used by examinees to guide their studies during test preparation.19 These test

maps ensure those external to the exam development process such as examinees and program

directors that the exam is balanced and fair with regards to the content tested. The use of

“medical content category” and “cross-content category” by the ABIM to define the question

categories can be compared to the proposal here within to frame radiation oncology education

not just by disease site (i.e. medical content category) but also by phase of care (i.e. cross-content

category).

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 In conclusion, the United States radiation oncology residency training curriculum is at

risk of developing one or more diseases of the curriculum. With proactive and methodologically

sound curriculum inquiry supported by national radiation oncology societies we can develop a

national curriculum to proactively guide training programs, trainees, and the board exam

development process while ensuring our patients – the most important curriculum stakeholders –

receive the highest quality clinical care achievable.

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References

1. Abrahamson, S. Diseases of the curriculum. J. Med. Educ. 53, 951–957 (1978).

2. Initial Certification Qualifying (Computer-based) Examination: Study Guide for Radiation

and Cancer Biology. (American Board of Radiology, 2019).

3. Weinberg, R. A. The Biology of Cancer. (Garland Science, 2014).

4. Curriculum Development for Medical Education: A Six-Step Approach. (Johns Hopkins

University Press, 2015).

5. Harris, I. B. Contributions to professional education from the field of curriculum studies:

Research and practice with new traditions of investigation. PERQ 13, 3–13 (1991).

6. ACGME Common Program Requirements. (2013).

7. Halperin, E. C., Wazer, D. E., Perez, C. A. & Brady, L. W. Perez and Brady’s Principles and

Practice of Radiation Oncology. (Wolters Kluwer Health/Lippincott Williams & Wilkins,

2018).

8. The Radiation Oncology Milestone Project. (2014).

9. American Board of Radiology. Response to September 26, 2018 letter of concern. (2018).

10. Burmeister, J. et al. The American Society for Radiation Oncology’s 2015 Core Physics

Curriculum for Radiation Oncology Residents. Int. J. Radiat. Oncol. Biol. Phys. 95, 1298–

1303 (2016).

11. Royal College of Radiology. Royal College of Radiologists Clinical Oncology

Curriculum. (2016). Available at: https://www.rcr.ac.uk/clinical-oncology/specialty-

training/clinical-oncology-curriculum. (Accessed: 14th March 2019)

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12. Royal Australian and New Zealand College of Radiologists Radiation Oncology Training

Program Curriculum. (2012). Available at: https://www.ranzcr.com/trainees/rad-

onc/curriculum. (Accessed: 14th March 2019)

13. Lee, W. R. & Amdur, R. J. A Call for Change in the ABR Initial Certification

Examination in Radiation Oncology. Int. J. Radiat. Oncol. • Biol. • Phys. 104, 17–20 (2019).

14. Wallner, P. E. et al. The American Board of Radiology Initial Certification in Radiation

Oncology: Moving Forward Through Collaboration. Int. J. Radiat. Oncol. • Biol. • Phys. 104,

21–23 (2019).

15. Urology Core Curriculum. American Urological Association Available at:

https://www.auanet.org/education/auauniversity/for-residents. (Accessed: 10th July 2019)

16. ASCO Self-Evaluation Program 6th Edition. American Society of Clinical Oncology

Available at: https://elearning.asco.org/product-details/asco-sep-6th-edition. (Accessed: 10th

July 2019)

17. Jarvis-Selinger, S. & Hubinette, M. The Matrix: Moving From Principles to Pragmatics

in Medical School Curriculum Renewal. Acad. Med. J. Assoc. Am. Med. Coll. 93, 1464–1471

(2018).

18. Leis, J. A. & Shojania, K. G. A primer on PDSA: executing plan-do-study-act cycles in

practice, not just in name. BMJ Qual. Saf. 26, 572–577 (2017).

19. Internal Medicine Certification Examination Blueprint. American Board of Internal

Medicine (2019) Available at:

https://www.abim.org/~/media/ABIM%20Public/Files/pdf/exam-

blueprints/certification/internal-medicine.pdf. (Accessed: 30th July 2019)

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Figure captions

Figure 1. Conceptual framework for radiation oncology clinical education structured on learner

obligations, Accreditation Council for Graduate Medical Education (ACGME) and Canadian

Medical Education Directives for Specialists (CanMEDS) core competencies, fundamental

knowledge of physics/radiation biology, research methodology knowledge, and the patient’s

clinical care path.7

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