IB Senior Educational Objectives - UCSF Radiation Oncology

Rev. 9/14/10
UCSF DEPARTMENT OF RADIATION ONCOLOGY
EDUCATIONAL OBJECTIVES FOR SENIOR RESIDENTS IN NEURO-ONCOLOGY
Igor J. Barani, M.D.
PATIENT CARE
In addition to the guidelines listed by the ACGME, senior resident must be able to provide
compassionate, appropriate, and effective treatment for patients. They must promote health
maintenance both during and after treatment. For each cancer patient, senior residents will be
expected to:
1. Communicate effectively and demonstrate respectful behavior when interacting with
the patient and her family/caregivers.
2. Gather essential and accurate information about the patient from the review of all
pertinent medical records and diagnostic tests, both within the UCSF medical
system as well as appropriate outside health care facilities (as necessary).
3. Gather pertinent information from the patient through interview history and physical
examination.
4. Counsel and educate patients and their families.
5. Develop and carry out management plans.
6. Select the appropriate technique and competently perform the procedures with
increased proficiency that are considered essential for the radiotherapeutic
management and follow-up of neuro-oncology patients and encountered on the
service, including:
a. External beam radiation therapy (IMRT, 3D-CRT) for definitive treatment of
CNS tumors.
b. External beam radiation therapy (IMRT, 3D-CRT) for palliative treatment of
CNS tumors.
c. Stereotactic radiosurgery (or radiotherapy) treatment techniques (e.g. Gamma
Knife, Cyberknife, or linear accelerator-based techniques) for definitive and
palliative treatment of various CNS conditions (benign and malignant)
d. CNS brachytherapy for recurrent disease.
e. Evaluate differential and cumulative dose-volume histograms (DVHs) for normal
and tumor tissues.
This process will include knowledge of all aspects of the simulation and treatment planning process,
including delineation and design of treatment fields, selection of photon/electron energy, beam
modifiers, radiotherapy dose and fractionation, identification an outline of tumor and critical organs
on MR and CT scans for the purpose of treatment planning, evaluation of treatment plans, and
evaluation of port films.
MEDICAL KNOWLEDGE
Senior residents will be expected to have a more in-depth knowledge of the following with an
increased emphasis on evidence-based medicine and knowledge of the pertinent literature:
1. Learn basic (and advanced) neuroanatomy, with an emphasis on axial imaging (e.g.
CT and MR imaging) as well as plain film radiography (use of bony landmarks to
localize lesions/radiotherapy targets).
2. Demonstrate familiarity with imaging modalities routinely used in neuro-oncology,
particularly MR imaging and various pulse-sequences used for treatment planning
(e.g. time-of-flight imaging for AVMs, SPGR sequences etc.)
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3. Demonstrate proficiency in neurological examination as well as a basic physical
exam. Learn to recognize neurologic syndromes which reflect the lesion(s), and
the subsequent evolution of these signs/symptoms during the course of
therapy/disease.
4. Understand the epidemiology, anatomy, and natural history, and pathophysiology of
various CNS tumors (both benign and malignant; primary and metastatic)
5. Be familiar with the role of molecular markers and gene expression profiles as
predictive and prognostic markers for disease recurrence and response to
treatment.
6. Know the classification of various CNS tumors (benign and malignant), including
grading of benign conditions such as arterio-venous malformations (AVMs).
7. Demonstrate knowledge base of factors that influence treatment decisions (clinical,
pathologic, and biologic)
8. Discuss management of primary and metastatic brain and spine tumors, including
indications for surgery and systemic therapy , and these modalities are integrated
with radiation therapy.
9. The junior and senior residents are expected to using the linear-quadratic (LQ)
model to predict acute and late toxicity, adjust fractionation schemes, and convert
between different fractionation schemes.
10. Demonstrate familiarity with acute and long-term side effects of radiation and their
management; for conventionally-fractionated or hypofractionated treatments as
well as radiosurgery (e.g. Gamma knife)
11. Know radiation safety principles, particularly with respect to use of sealed sources.
PRACTICE-BASED LEARNING and IMPROVEMENT
Residents must demonstrate the ability to use information technology and feedback to improve their
fund of knowledge and skills. The expectation is that they learn how search, review, and analyze
medical information in PubMed as well as the UCSF Medical Library.
INTERPERSONAL and COMMUNICATION SKILLS
All residents are expected to:
1. Communicate with patient and their family/caregivers in an easily understood and
culturally sensitive manner.
2. Communicate effectively with medical and support staff, demonstrating respect and
maintaining professional relationships with all members of the radiation oncology
team.
3. Communicate with other physicians and health care professionals.
4. Work effectively as a team member, progressively accepting more responsibility and
participate in a leadership role as progressing through the residency.
5. Maintain comprehensive, accurate and timely medical records. All relevant medical
records must be completed within 48 hours of the patient visit.
PROFESSIONALISM
All residents are expected to:
1. Demonstrate compassion, respect, and integrity and responsiveness to patient's
needs.
2. Be accountable to their patients and their profession.
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3. Be responsive to the needs of the referring/primary healthcare team; completing
patient-care tasks in a timely and responsible manner (especially in the inpatient
setting) so as not to delay or impede patient’s further care or discharge from the
hospital.
4. Demonstrate a commitment to excellence and on-going professional development.
5. Function well as a member of the team.
6. Practice in an ethical manner with regard to provision or withholding of care,
confidentiality of PHI, and informed consent.
7. Maintain comprehensive, accurate, and timely medical records.
8. Function as role models and mentors for junior residents.
SYSTEM-BASED PRACTICE
Senior residents will demonstrate an awareness of and responsiveness to the health care system and
ability to call on resources to provide care. They are expected to:
1. Understand how their professional patient care practices affect other health care
professionals, the healthcare organization and the community.
2. Practice cost-effective health care that does not compromise quality of care.
3. Advocate for quality patient care practices and help patients navigate through
complexities in the healthcare system.
4. Be able to partner with healthcare managers and providers to access, coordinate, and
improve health care; be aware of how these activities affect system performance.
LIST OF SPECIFIC EXPECTATIONS
The following is a list of specific expectations for resident physicians in training at UCSF while
assigned to the Neuro-Oncology Service In Radiation Oncology. The goal of the list is to facilitate
learning, improve patient management skills, and to improve knowledge of relevant literature and its
application to the individual patient.
1. Be prepared to discuss relevant literature with attending physician(s). Literature
should be reviewed in advance of patient presentation to the attending physician.
The reference reading list will be located on the department server and many
seminal articles which apply to the daily practice will be provided on the server in
the PDF format. Additional reading recommendations will be made by the
attending physician as indicated.
2. Attend relevant CNS conferences:
a. Pediatric and Adult Neuro-Oncology Conference (Thursday, 12:30 – 2:30 pm,
weekly)
b. Radiosurgery Conference (Thursday, 2:30 – 3:30 pm, weekly); starts immediately
after the Neuro-Oncology Conference
c. Skull Base Conference (Thursday, 3:30 – 4:30 pm, first week of every month)
d. Spine Tumor Conference (Wednesday, 7:30 – 8:30 am, third week of every month)
e. CNS Chart Rounds (Wednesday, 8:00 – 9:00 am, weekly)
3. Check and sign port films with the attending for on-treatment patients weekly.
4. Gamma knife: Participate in the simulation, planning, and treatment delivery of
radiosurgical procedures. The residents are expected to remain in the Gamma
knife control area for the entire duration of the patient’s procedure. They are also
responsible for helping the attending physician position the patient for treatment
and then for helping to remove head frame post-treatment. They are also
expected to assist the attending physician with providing patients post-treatment
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care instructions (including any required prescriptions etc.). The residents are also
expected to participate in the management of acute and late toxicities of therapy.
5. CyberKnife: Participate in the simulation, planning, and treatment delivery. They
must accompany the attending physician to verify treatment setup of the first
treatment fraction (if multiple treatment fractions are given). They are also
expected to assist the attending physician with providing patients post-treatment
care instructions (including any required prescriptions etc.). The residents are also
expected to participate in the management of acute and late toxicities of therapy.
6. Brain Brachytherapy: The resident is responsible for actively participating in the
procedure, accompanying attending physician to the operating theatre, assisting in
the seed placement, documenting and observing relevant safety protocols,
providing patient and family members with post-implant instructions.
7. Read/Study
A list of relevant reference articles will be located on the department server for
resident download.
8. Maintain service list of patients (current, past, and pending) and continue to update
the list to ensure adequate follow-up of pending patient care items.
9. Neurocognitive Clinic (Tuesdays)
a. On Tuesday of every week (pending a clinic change), the residents are expected to be
in the clinic with Dr. Caroline Racine (in-house neuropsychologist) to learn and
observe how to take a cognitive history and how to administer cognitive screening
exam (MOCA). They will also be expected to learn the basic brain-behavior
relationships and effects of intervention on neuropsychological test results.
b. The residents will be supervised on this day by Dr. Racine and are responsible for
completing any reading or tasks assigned.
10. New Patients
a. Obtain records and prepare for patient prior to their arrival. Present case to
attending as indicated. Identify clinical issues and questions raised by a specific case.
Make recommendations for patient’s care based on evidence found in literature. Cite
relevant literature in summary write-up. Discuss relevant literature with attending.
b. Devise and review treatment plan based on patient indications and planning.
c. Follow-up on pending surgeries, pathology, medical records, imaging, and other
relevant clinical patient information.
d. Attend all simulation visits; order relevant simulation studies.
e. Be prepared to discuss risks and benefits of radiation therapy with patients when
requested by the attending physician.
f. Attend all new patient starts and review port films at the treatment machine.
g. In treatment planning, the resident is responsible for contouring the following tumor
and normal tissue structures:
i. Cranial Cases:
1. Tumor (or surgical cavity); GTV, CTV, and PTV (as indicated)
2. Bilateral Eyes
3. Bilateral Optic Nerves
4. Chiasm
5. Bilateral Cochlea and Vestibular Apparatus
6. Pituitary Gland
7. Hypothalamus
8. Bilateral Temporal Lobes
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9. Brainstem (from the cerebral peduncles to the foramen magnum)
10. Bilateral Parotids
11. Spinal Cord (from the foramen magnum to C2)
ii. Spine Cases:
1. Tumor (or surgical bed); GTV, CTV, and PTV (as indicated)
2. Spinal cord (two vertebral body levels above and below the target)
3. Relevant, treatment-level specific surrounding normal tissue
structures (e.g. small or large bowel, heart, lungs, thyroid, etc.)
h. Calculate dose-volume histograms, both differential and cumulative, and understand
the relevant thresholds.
i. Become familiar with management of acute and late radiation reactions (e.g. radiation
necrosis)
j. Document in Lantis (or equivalent department medical record system) the following:
i. Date of initial diagnosis
ii. Date of consultation
iii. Treatment site (ICD-9 code)
iv. Tumor stage/grade information
v. Histology
vi. Simulation note, describing simulation position, immobilization devices, type
of simulation (PET, CT, MR, or fluoroscopy), specific scan instructions (e.g.
scan slice thickness, gap, +/- contrast etc.)
vii. Treatment site, modality, energy, dose/fractionation
viii. Notify medical physicist(s) if specific pre-treatment checks (e.g. TLDs) are
required
11. On-Treatment Patients
i. Be aware of issues and status during treatment.
ii. Maintain on-treatment list of patients; document on-treatment issues in
Lantis (or equivalent electronic medical record system); notify attending of
any patient-specific issues/complications
iii. Check weekly port films with attending physician; respond to therapist
inquiries regarding patient care issues
12. Follow-up Patients
i. See follow-up patients with attending physician; document follow-up visits in
a clear, concise manner, and communicate with relevant services to ensure
proper management and follow-up of patients (e.g. ensure follow-up visits
with medical oncology for systemic therapy etc.)
ii. Obtain recent test results, imaging and clinical notes on patients in advance
of appointments and review with attending; this includes relevant medical
records from outside medical facilities.
13. Understand machine- and patient-specific QA practices for external beam
treatments.
14. Obtain training in emergency procedures of each treatment modality used (e.g.
Gamma knife, Cyberknife, linear accelerator, and brachytherapy) and document
proficiency.
15. Final Examination (supervised)
Senior resident is responsible for overseeing and leading the consultation,
simulation, planning, plan evaluation, and treatment delivery of a definitive CNS
treatment case (e.g. glioma, meningioma, etc.). The resident will be evaluated on
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the adequacy of treatment (target coverage, dose, fractionation) and safety
(observing well-established dose-volume critical structure thresholds). The
resident will be closely supervised throughout the process by the attending
physician, but will be responsible for presenting and justifying the entire treatment
plan, including decision to treat using any available supporting evidence. It is
possible to fail the examination by exceeding normal tissue thresholds in the
absence of proper justification, causing potential harm to the patient, or by undertreating
the tumor.
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