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Radiation Oncology

About the Specialty

What do radiation oncologists do?

Radiation Oncologists use ionizing radiation for the treatment of cancer as well as a few benign medical conditions. The field focuses on prescribing and planning the appropriate treatment, ensuring that the treatment is properly administered each day, managing any complications of treatment, and following the patient after treatment to manage late side effects and monitor the status of disease.

Who do I work with?

Radiation Oncologists work with a team that also includes physicists, dosimetrists, radiation therapists, and nurses. In most academic centers, they also work as part of a multidisciplinary team that includes medical oncologists, surgical oncologists, radiologists, and pathologists. About 50% of patients are treated with curative intent, while the remainder of cases are treated palliatively, (e.g., for pain relief from bone metastases). A small percentage of patients are treated for non-cancerous conditions such as trigeminal neuralgia or keloids.

What are some other things I should know about the day to day?

The specialty is highly academic with a focus on physics, radiobiology, molecular biology, and evidence-based medicine. Imaging and computer treatment planning are also a major component. Radiation oncologists divide their time between seeing patients (inpatients and outpatients), performing procedures (such as radioactive implants), and creating/evaluating treatment plans. In the academic setting, radiation oncologists often dedicate a significant portion of their time to research (clinical or basic science).

What about after residency?

Residency graduates may go on to work in academics, satellite facilities associated with academic centers, community hospital-based practices, and private groups.

About the Residency

What’s the training like?

Residency is four years (PGY-2 to PGY-5). The PGY1 year can be done as a preliminary year or a transitional year. Most programs do not offer a PGY-1 year, so the applicant needs to apply for and interview at PGY-1 programs separately. However there are some programs that require you to fulfill your PGY-1 year at their hospital (Penn, Emory, Cleveland Clinic). It is important to note that you can have a separate preliminary/transitional program rank list for each Rad Onc program that you rank.

Programs are generally structured so that you have responsibility for patient care and treatment planning from the very beginning of your training. As you progress through the residency, you are expected to function more independently from attending supervision. Graduating from residency is dependent upon your completing a certain number of cases for each required site. A number of programs do not have a sufficient caseload in certain areas, usually Pediatrics or Gynecology, for you to complete your cases and you will have to go elsewhere for 4-6 weeks to fulfill these requirements. Most programs where this happens have formal arrangements with a large center, e.g., all Maryland residents go to St. Jude’s for their Pediatric elective.

Do I get time for Research?

Most programs require 3-12 months of research (clinical or laboratory). Some require the resident to publish an abstract or manuscript before graduating. Required or not, the emphasis on research that’s seen in the resident selection process continues throughout residency at most programs. There are a few smaller programs where this may not be as strongly emphasized.

How do I learn the physics?

Most residency programs offer formal (i.e., a few hours of lecture per week) protected lectures in physics and radiobiology in addition to hands-on clinical didactics. You are tested in radiobiology and physics on the board exams, so expect to devote some hours each week to learning these subjects.

What is call like?

There is no in-house night call for radiation oncology residents. However, most if not all programs have the residents take beeper call from home, usually for one week at a time. During call you would be expected to address patient problems at night and on weekends as well as consults for radiation oncology emergencies such as spinal cord compression that may require immediate treatment.

Other work outside the hospital: Most residents devote a few hours each night to reading, since in addition to physics and biology, residents are also expected to be familiar with (i.e., quote and know the implications for the standard of care) important clinical studies for each cancer site and stage. This requires a lot of review and repetition of textbooks and journal articles.

Applicant Characteristics

What are some general things I should know before applying?

Most programs are looking for applicants who show interest in the clinical as well as research aspects of radiation oncology and molecular biology. Positions are extremely competitive, and good numbers (boards/clinical year grades) and publications within the field of radiation oncology or cancer in general are important in finding a residency position.

What about Step 1 scores?

Many of the so-called elite programs have board score cutoffs in the 220’s and possibly even as high as 230. However, applicants with average board scores can be competitive if they have other outstanding characteristics, such as research publications, an MD-PhD, or AOA status. Beware that some programs favor MD-PhDs more than others. Grades in Rad Onc electives are particularly important; try to get A’s/Honors in these. Other important rotations are Medicine, Surgery, and Ob-Gyn. There is also data available from the NRMP that is helpful to get an idea of what characteristics make applicants competitive in the Radiation Oncology match.

So should I take step 2 early?

You can if you want to boost your step 1 score, otherwise you can wait until after your application goes out to programs. What about Letters of Recommendation? Also see below in ‘The application process’ In addition to academic abilities, most programs are also looking for applicants who can fit in and work well with the people in their small departments, so personality and letters of recommendation are important as well. As a small field, letters of recommendation from nationally-known faculty members can go a long way towards interview offers. Plan on getting at least 2 letters from someone in radiation oncology, and then the other 2 can be a mix of research or from an attending you worked with on any core third year rotation, or better yet a SubI.

Do I need research on my app?

Because Rad Onc is a research-intensive field and has become so competitive, some research in the field is almost an absolute requirement. Publications are impressive, but any research experience which shows your interest and commitment to the field will be helpful. The attendings and residents at Maryland are very supportive and willing to help you set up research experiences.

Who can I talk to at UMD?

You need to be aggressive about getting such projects though. The residents are a great starting point in setting up research projects and can help direct you to faculty with ongoing projects. In particular, Dr. Vujaskovic has a thriving lab if you are interested in bench research and Dr. Simone, as well as many other faculty members, is very active in clinical research.

The Fourth Year Schedule

Should I take a year off?

A year off is NOT completely necessary. Many applicants each year still match without taking a year off. That having been said, if you have little research experience and have less-than-stellar board scores and grades, taking a year off may be necessary in order for you to match. It is possible to complete research from scratch during the latter half of third year and into fourth year, but requires hard work and no small amount of luck. Case reports are not commonly published in radiation oncology, so getting published isn’t as easy as simply being motivated and willing like in some other fields. It takes time. Getting at the very least a poster presentation under your belt is nearly required. Keep in mind, you are competing against MD/PhDs. Taking a year off may help put you over the edge into gaining interviews at stronger programs.

If I want to take a year, when should I do it?

If planning on taking a year off for research, it would be most helpful for you to do it between third and fourth year. This way, you have a whole year to perform research and generate publications, get LORs, and gain knowledge in the field, before going on to your fourth year radiation oncology electives. Taking a year off after fourth year may not be as useful or productive, as you really only have from May-September to do research before the application cycle begins, which is not that much time to get research and potential publications completed.

How should I plan my fourth year schedule?

Remember that grades from any rotation done after September of your fourth year probably will not make it on your ERAS transcript in time for evaluation by residency programs. However, letters of recommendation and updated transcripts can be sent directly to programs even after ERAS closes.

What about Away Rotations?

There are two major schools of thought regarding away rotations. You can rotate at a big name place and score a big letter, but most of these places will not guarantee an interview to rotating students. Another option is rotating at a less prestigious institution and potentially impressing the department enough to get an interview and/or even a position. It is important to discuss these options with your advisors and make an informed decision. Geographic location is another consideration. Doing an away rotation in a certain region will often gain you consideration by other schools in that region, as it suggests you would be willing to go to that part of the country for your residency training. You can often find applications for away electives on the different programs websites, but most programs now use VSLO.

How many should I do and when?

You should plan on doing at least two radiation oncology electives before October of the fourth year – one here at Maryland and an away rotation. Spend one month at your top program choice whenever possible. It is possible that during July you may get lost in the shuffle since new residents are getting a lot of attention from attendings. On the other hand, the earlier you start with rad-onc electives the more time you have to get LORs, and the less stressed out you will be as the time comes closer to start ERAS. Arrange for away electives early (as early as January of the third year- there is associated paperwork including immunization forms that differ from institution to institution), because they can be difficult to get, especially at top programs (such as Sloan- Kettering or MD Anderson).

What about a Sub-I?

Some programs like to see sub-I grades, soif you are able to complete a sub-I before November that is ideal, but this is not crucial. The inpatient Cancer Center month is a great choice, and may provide a chance to get a letter from a prominent medical oncologist, which can be helpful as well. Alternatively, a Medicine Sub-I, would be a good choice. A Surgical Oncology Sub-I may be particularly impressive, but beware that you likely need to do a Medicine Sub-I (Cancer Center counts) early on in the year in order to apply for a preliminary medicine year. Note that you can do a preliminary surgery PGY1year if you wish, but this is uncommon due to the significantly increased workload compared to preliminary medicine or transitional years.

When should I schedule interviews?

You should try to schedule preliminary/transitional year interviews as early as possible (October/November) to get them out of the way. Most radiation oncology interviews are from early December (even a few before Thanksgiving) to the very end of January and even into early February. Try to take one of these months off and schedule a flexible elective in the other. DO NOT schedule a sub-I in these months. Technically, you are only allowed to take off 2 days for interviews during a sub-I, 3 during AHEC, and 4 during an elective. Some electives may be stricter with this policy than others.

*** Because of the small number of applicants that are interviewed, each program interviews on only a limited number of dates (typically 1-3). This means that there is very little flexibility when it comes to scheduling interviews and some programs interview on the same date. Because of this, it is important to schedule interviews as soon as you receive an invitation since spots fill up FAST (some programs send more invitations than they have spots for interviews). A matter of twenty minutes can make a difference. Checking your smartphone frequently is an absolute must. Replying within minutes of receiving your invitation is ideal. Radiation Oncology tends to send out interview invitations later than most other specialties. Most interview invitations will be sent out after the dean’s letter is received, from mid-November through the end of December. Additionally, you may get off a program’s wait list well into January. You will be waiting until after ASTRO for most interviews. Your friends WILL get interviews before you, and this will lead to anxiety. SDN can be a resource to see which programs have sent out invites, HOWEVER, it can also serve as a great source of anxiety since the average applicant will get 3-4 times more rejections than invitations to interview. You will likely have interview day conflicts and be forced to choose between programs, which can be very frustrating.

The Application Process

Most programs now use ERAS although there are still a few that do not (e.g. NCI). If interested in applying to non-ERAS programs, applicants can often find application materials on-line at the program’s website or request them by calling the program directly. Applications should be completed as early as possible as deadlines for some schools may be in September. Regardless of the deadline, the earlier, the better. Also be advised that some programs might not be accepting applicants in the year that you apply and occasionally the only way to find that out is after you apply. However, usually the studentdoctor.net forums will discuss which programs are on probation and are not accepting residents for that year.

How many should I apply to?

Plan to apply to 30-60 programs, although it is not uncommon to apply to every program (~80); expect to receive interview invitations from about 1/4th of the programs where you applied. Some programs may strongly preference M.D./Ph.D applicants, so it is important to know about each program before applying. Apply to a wide range of programs and regions. It is very difficult to predict which programs are likely to interview you or even find a pattern amongst programs that do offer you an interview. It will baffle you. If you have a strong interest in interviewing at a certain program, feel free to e-mail them and express this interest, giving a compelling reason why you want to be there (close family in the area, etc). For example, if you have no apparent ties to (insert state here) on your application, but your significant other’s entire family lives there and you want to relocate, e-mailing the programs nearby can’t hurt.

More about letters please?

Letters from department chairs in Rad Onc and from well-known physicians in the field are extremely helpful. Most programs ask for 3 letters; some only look at letters from radiation oncologists. Get letters from Dr. Regine (Chairman of Radiation Oncology) and/or Dr. Suntha (President and CEO of UMMC) at Maryland. Dr. Simone and Dr. Vujaskovic are also well known for their research contributions. Additionally, you should plan to get a letter from a well-known attending at each of your away rotations if possible. Be VERY careful with your letter writers. Residents—even at your away rotations—will have a good sense of who would write a good letter. Try to identify who you plan to ask early in your rotation so that you can spend more time in the clinic with them and allow them to write a stronger, more personal letter.

Check out The Association of Residents in Radiation Oncology website (www.arro.org) for a list of all the Radiation Oncology residency programs in the U.S., the number of residents in each program, the program director’s name, and the contact information for each program. This website is more accurate than FRIEDA. Other good online resources include the Radiation Oncology forum at http://forums.studentdoctor.net and the residency program reviews at www.scutwork.com.

Match Statistics

The match is quite competitive. There are currently about ~180 residency positions at 83 accredited Rad Onc programs in the U.S., with program sizes ranging from 4-20+ residents (1 to 7 per year). Most programs receive 100-300 applications and interview 10-30+ for an average of two positions. This current application cycle of 2017-2018 most programs received well over 200. Statistically, if you can rank 10 programs by the end of the interview season, you have an approximate 95% chance of matching. That having been said, there are anomalies every year, and even very strong candidates on paper may go unmatched if they don’t interview well. Rotating at a department and putting on a good performance is truly a way to increase your chances of matching there. But by no means does this ever guarantee you a spot, even if they give you praise and positive feedback on your rotation. In the past, thank you notes were standard and post-interview communications (including informing your #1 program), however, there has been a movement to “take the game out of the match” that is now embraced by most well-respected academic program. Prior to interviewing, you should read these articles (https://www.ncbi.nlm.nih.gov/pubmed/26581129 and https://www.ncbi.nlm.nih.gov/pubmed/26972659) that lay out the guidelines that most programs have pledged to follow (pay special attention to programs listed on the original publication and the response so you know what is acceptable for each program on your interview list). Second looks can usually be arranged, if you wish. Most programs will tell you second looks do not affect how they rank a candidate.

Few residency graduates pursue fellowship, but the most common one is pediatrics. Proton therapy fellowships are also available. Graduating residents generally have little difficulty finding a job. Procuring a job in a competitive market, however, is not as easy. Academic positions at the main campus of a university hospital in a desirable city are difficult to come by. Positions with satellite facilities of academic programs and private groups are much easier to find. There are always job openings in rural areas.

Interview Day

Interviews also play a vital role in the selection process. Interview days are very long; often you are interviewed by 6-12 attendings for 15-30 minutes each. Most places will also have you interview with faculty from the Physics and Radiobiology division and some places (e.g. Florida, Wisconsin, MD Anderson) have panel interviews. Make sure you are very familiar with your research and read up on the program a little bit (from information packets or web sites) prior to your interview. Other popular topics of discussion include how you got interested in Rad Onc, why you are interested in Rad Onc as opposed to Medical or Surgical Oncology, your strengths/weaknesses, and your career goals. A dreaded yet common question: why do you want to come HERE versus other places you have interviewed/rotated?

What to Look for in a Program: Questions to Ask Your Interviewers

  • How are physics and biology taught?
  • What updates/changes in the program are expected during your residency?
  • What kind of jobs have recent graduates gotten?
  • What types of research have residents recently published?
  • Do Residents have the opportunity to present their research at national conferences?
  • What is the board pass rate?

Although, it is important to note that these differences can be subtle and not immediately evident from the information presented during the interview day. Make sure you have stock questions in your head to ask during your interviews so that you do not come off looking disinterested in the program. You will be hearing the phrase “what questions do you have for me?” in your nightmares for years to come.

Other Things to Consider

How much scutwork (e.g., tracking down medical records, pulling films) do the residents do?
What is the attendings’ attitude towards teaching (malignant/supportive/indifferent)?
What is the atmosphere of the department (formal vs. informal)?
Does the department perform a sufficiently wide range of procedures to equip you for your future practice?
Strengths of the department. Some departments are particularly known for certain disease sites (University of Florida: head and neck, and pediatrics; Thomas Jefferson: CNS. Etc.)
How old/new are the treatment machines and planning equipment?
Cost of living in the surrounding area.
Workload. At some programs, residents legitimately work most days from about 8am-4:30pm.
At other programs they will work consistently from 7:30-6:30pm+, or even later especially for new residents getting into the swing of things.
***Are the residents satisfied with their learning and clinical experience?***

Outstanding Programs

These programs are great places to do electives, research, and residency: MD Anderson (Houston, TX); Memorial Sloan-Kettering (New York, NY); Harvard (Boston, MA); UCSF, (San Francisco, CA); Stanford (Palo Alto, CA); University of Chicago (Chicago, IL); University of Pennsylvania (Philadelphia, PA); Johns Hopkins (Baltimore, MD); University of Florida (Gainesville, FL); University of Michigan (Ann Arbor, MI); Duke University (Durham, NC); Yale (New Haven, CT); University of Colorado (Denver, CO), University of Maryland (Baltimore, MD)

Good Luck!!

Last Revision: March 9, 2018