Radiation Oncology Residents Report Deficits in Training During the Pandemic

SAN DIEGO — While most radiation oncology residents believe they were able to make it through the COVID-19 pandemic with the training necessary to independently practice in the field, the experience has left them with concerns about their future job prospects.

The pandemic experience also raised questions about the way radiation oncology residents should be trained going forward, said Macklin Nguyen, MD, a resident in the radiation oncology department at the University of Washington in Seattle.

These were just some of the issues addressed during a session at the Association of VA Hematology/Oncology annual meeting.

Session moderator Tony Quang, MD, of the University of Washington School of Medicine and a past-president of the association, pointed out that since Seattle was at the epicenter of the COVID-19 breakout in early 2020, it hit the residents at his university particularly hard.

“We had to scramble to take care of our patients, and residents were asked to go to the front lines for coverage,” he recalled. During subsequent surges, residents have also been shifted from their usual training to take care of COVID patients, he added.

“That never really happened to me, but it was certainly something that I viewed with some anxiety and trepidation,” said Nguyen, noting that an international survey of residents and fellows showed that increasing COVID patient load was linked with burnout. Compared with residents who were not exposed to COVID care, patients who had a patient load of one to 30 patients had an adjusted odds ratio of burnout of 1.80, which increased to 4.03 with case loads of over 60 patients.

As for the impact on radiation oncology training, Nguyen said that his patient volume is just now returning to pre-pandemic levels, “but certainly there is an increased issue of virtual everything, whether that’s didactics, tumor boards, patient care, education, and conferences.”

The increase in virtual learning has pros and cons for trainees, he said. For example, it has allowed increased access to tumor boards, cost- and resource-prohibitive formats such as in-person academic conferences, and patients in remote geographical areas.

However, “passive learning is also challenging,” he added. “And as a resident, we often follow an apprentice-style learning system, working one-on-one with an attending physician. That in itself can be isolating in nature, and becomes even more isolating with Zoom meetings instead of not meeting face-to-face.”

He also pointed out that less in-person learning and fewer interactions with patients prohibit trainees from learning non-verbal social cues during physical examinations, which can’t be replicated virtually.

Referring to another survey of 96 residents across 67 U.S. radiation oncology programs that was designed to assess the impact of COVID on training and wellness, Nguyen pointed out that the pandemic significantly affected the amount of training residents have received for certain procedures, as well as their mental and emotional well-being.

For example, a large majority of residents (82.3%) observed an increase in the use of hypofractionated treatment (in order to shorten the course of radiotherapy and reduce patients’ COVID exposure), while 65% reported that the pandemic led them to see fewer patients in a normal week. Furthermore, one-third experienced less training in brachytherapy.

As for individual well-being, 58% reported experiencing an increased level of anxiety, 30.2% reported burnout, and 25% reported an increased level of depression.

Importantly, many residents believe that the pandemic will negatively affect their career prospects, with 51% responding that they either agree or strongly agree that the pandemic will affect their ability to find a job. However, 85% of residents agree or strongly agree that despite the challenges raised by the pandemic, they’ve been adequately trained to independently practice radiation oncology.

“I think moving forward, the question is, how to we want to continue residency training?” Nguyen said. “Do we want to continue with virtual didactics and learning? And what are the pros and cons of going back to the more traditional model?”

“In my experience so far it’s been a hybrid,” he noted. “I enjoy the fact that tumor boards are not in person because we are all working at multiple sites and we can chime in and learn, even if we’re off rotation. But I do appreciate that for a case conference, we’re there in person. It’s a more Socratic method of questioning back and forth. You learn a lot from that process and you learn the most from your mistakes.”

Residents were as integral to patient care as any other hospital staff during the pandemic, Quang said. “I hope that other residency directors across the country listen to this talk and see what the residents went through.”

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