This is a one-year fellowship program designed to familiarize the trainee with the indications for, techniques of, and results from proton radiation therapy treatment. Trainees will spend 9 - 12 months of the year on clinical radiation oncology services which use proton radiation therapy. Three months of the year may be spent on clinical, physics, or biology research projects related to proton radiation therapy. While on clinical service, fellows will be expected to evaluate new patients under consideration for proton/photon radiation therapy, dictate appropriate consultation notes, present the patient for discussion at Proton Rounds in the Department of Radiation Oncology and at other appropriate multidisciplinary patient management conferences (i.e. Sarcoma Conference, Pediatric Tumor Board, etc.), review diagnostic studies with the attending Radiation Oncologist and specialists from other services (i.e. Pathology, Diagnostic Radiology), and actively participate in the Proton/Photon Radiation Therapy treatment planning process. Currently, there is one fellow accepted for year-long proton fellowship position.
Goals of Fellowship Program
- Provide an in-depth clinical exposure to radiation therapy with protons.
- Develop understanding of physical interactions of protons with tissue and understanding of treatment planning with protons
- Develop familiarity with clinical indications for use of protons.
- Develop understanding of differences in clinical proton and photon dosimetry.
- Develop understanding of normal tissue constraints utilized in proton radiation therapy planning.
- Develop understanding of clinical radiation therapy target volumes for proton radiation therapy.
- Refine understanding of most relevant tumor imaging
- Become familiar with the relevant literature, which documents the most appropriate treatment strategies for patients undergoing proton radiation therapy
- Become competent in radiation therapy planning and delivery in patients undergoing proton radiation therapy, including use of required immobilization and CT simulation. The fellow should become proficient in the use of various immobilization strategies (casts, bite blocks), CT simulation techniques, and image fusion techniques. Time should be spent in the mold room observing immobilization devices being made.
- Become familiar with ongoing clinical research trials available to patients with these malignancies.
- Recognize patient factors such as age, performance and nutritional status that influence treatment management recommendations and tolerance of therapy.
- Become knowledgeable regarding treatment outcomes so that these can be discussed with the patient, family, and primary care and other involved physicians.
- Develop the communication skills required to deal with patients and their relatives following the diagnosis, during treatment, and on relapse should it occur. To develop a sensitivity and awareness of end of life issues.
- Become competent in the palliative management of these patients including pain medication management.
- Proton radiation may be used for benign disease such as arteriovenous malformations, meningiomas, acoustic neuromas, giant cell tumors, and others. The careful selection of cases and therapy will be taught.
Clinical rotations will generally consist of clinical days evaluating new patients and those undergoing proton/photon radiation therapy and days for radiation therapy planning and other clinically relevant activities. Clinical rotations for the fellow will be selected by the program director. The currently available rotations will include Central Nervous System, Base of Skull, Head and Neck, Sarcoma, Pediatric, and Gastrointestinal. These will generally be 6-week in length. Other clinical rotations may be selected should there be sufficient clinical proton treatment volume and interest by the fellow. No arrangements are currently in place for rotations at other institutions. Fellows will not bill for their services; billing will be performed by the attending radiation oncologist supervising the fellow.
These can be subdivided into clinical, physics, and biologic research opportunities. Clinical research opportunities include involvement in ongoing, IRB-approved proton clinical trials, the opportunity to write new clinical trial protocols in conjunction with radiation oncology attendings, and participate in the collection, analysis, and preparation of IRB-approved clinical research studies evaluating clinical proton radiation therapy. Opportunities are available to collaborate with proton physicists studying clinically relevant proton physics questions (i.e. treatment planning comparisons of protons versus photons). Similar opportunities are available to collaborate with radiation biologist studying clinically relevant proton radiobiology questions (i.e. relative biologic effectiveness of protons compared to photons). Harvard guidelines for presentation and authorship will be used.
We will make every effort to make funds available to support fellow travel to a national oncology meeting. Additional funds will be sought for presentation of research finding arising from their research projects.
Evaluation will be provided in two formats:
Informal, ongoing evaluation throughout the individual rotations. Fellow will receive and be expected to become familiar with the goals of the fellowship Staff will offer ongoing input, feedback, and encouragement to the resident so that the fellow and staff can assess whether performance expectations are being met. This process should begin immediately upon the start of the rotation, to maximize opportunities for interventions if performance deficits are noted. If staff recognizes performance deficits, this should be communicated to the fellow on the service and, in conjunction with the fellowship director, corrective action(s) should be instituted.
Formal written evaluation: Departmental fellowship review form to be completed by staff at the completion of the rotation. The program director will meet with fellow at least twice yearly to discuss, as well as provide career counseling and obtain feedback from the fellow about the program and faculty. The program director will ensure that teaching faculty evaluate the trainees in writing at least twice yearly and provide frequent, timely verbal feedback. The program director will keep a file of written evaluations on each trainee.
Teaching Experience Evaluation
Fellows will be asked to comment on their learning experience on the rotation and communicate this information to the fellowship director through a formal evaluation instrument.
Three weeks of vacation time are allotted for the fellows. Sick leave, maternity leave, and paternity leave will be allotted according to Partners policies for residents.
Service and On-Call Responsibilities
Fellows are not scheduled to take evening, night or weekend call but are expected to be available to see patients during the treatment day (currently 7:30 a.m.- 6:30 p.m.) on an as needed basis. Fellows are expected to be carrying a beeper and be available for paging during this time period. Appropriate cross cover arrangements (i.e. by the other proton fellow, radiation therapy resident, or radiation therapy staff) with the approval of the Medical Director of the Proton Center can be arranged to allow for uninterrupted periods during which fellows may be engaged in research projects or other clinical pursuits. The program director will ensure that the educational process is not undermined by excessive service requirements and that appropriate back-up and supervision are provided at all times. Moonlighting is allowed, with approval of the Medical Director, provided it does not interfere with the responsibilities outlined above.
The standard Partners contract will be amended as necessary to reflect specifics of the fellowship program. A contract should be signed by each fellow each year. A copy of the contract should be provided to applicants no later than the time that they are offered a position.
Educational Content and Didactic Activities
The resident will spend their clinical rotation on the particular proton radiation therapy service Service, working closely with radiation oncology specialty board-certified, attending radiation oncology staff involved in the care of these patients. The attending physicians will supervise the fellow directly as they see selected in-patient consultations as well as selected outpatient new patient consultations in the Radiation Oncology and the combined modality, multidisciplinary clinics. Selected follow-up patients who provide appropriate education opportunities for the fellow will also be seen. Supervision and teaching during these clinic sessions will include review of the patient presentation, discussion about patient work-up, review and discussion of pertinent imaging, discussion and formalization of a treatment plan.
The fellow will see patients weekly during their radiation therapy and be available at other times during the week to see patients experiencing treatment-related complications. Fellows will be expected to work with residents and students on the clinical service, offering guidance and teaching to the more junior trainees based upon the greater clinical experience of the fellow. Patient assignment will be based upon departmental guidelines that recognize the other demands on and responsibilities of the fellows, such as treatment planning and time for reading and study.
Treatment planning will be performed by the fellow in selected cases with direct supervision by the attending radiation oncologist. This will include discussion of the type of treatment immobilization, discussion of the appropriate CT treatment planning technique (intravenous, oral, and or intrathecal contrast, slice thickness, anatomic region and appropriate margins to be scanned), acquisition and fusion of additional tumor imaging (PET, MRI), contouring of the clinical target volumes, and in-depth review of the target volumes, target dose prescriptions, and normal tissue constraints with the attending radiation oncologist.
Didactic activities will include one-hour morning teaching conferences in the Department of Radiation Oncology (Monday, Wednesday, Thursday, Friday), one hour chart Rounds on Tuesday morning, weekly Proton Rounds on Tuesday morning, Physics research presentations on Tuesdays, Proton Eye rounds on Wednesdays, monthly Proton research meetings, monthly Radiation Oncology Journal Clubs, as well as multiple subspecialty tumor boards and teaching conferences.
Teaching can be formally divided into:
Faculty precepting, one-on-one, as patients are evaluated, planned, and treated.
Conferences: Fellows are expected to attend and participate in regularly scheduled teaching conferences on the assigned clinical service.
Individual study: Pertinent references will be provided to fellow by staff.
Fellow is expected to read:
Chapter(s) in appropriate Radiation Oncology textbooks on Proton Radiation Therapy.
Literature reprints of references provided to fellow by staff. These will change frequently as the literature evolves.
The fellow will present on a regular basis (a case discussion of appropriate teaching cases) at the regularly scheduled department teaching conferences with attending staff radiation oncologist present to add additional instruction as indicated. Relevant conferences include resident teaching conferences (Mon, Wed 8-9 a.m.), weekly proton rounds on Tuesday at 09:15 a.m. (NPTC Conference Room), weekly chart rounds (Tuesday 8-9:15 am), monthly Radiation Oncology Journal Club, and service specific conferences.
Fellowship applicants will submit a letter of interest and their CV. These will be reviewed by the Fellowship Director and Medical Director of the Proton Center. Radiation Oncology Senior Executive Committee. Applications must be received by December 1 of the year prior to initiation of training. The application review and selection process are expected to be completed by April 1 of the fellowship year. The most promising candidates will be scheduled for a visit to the facility to meet with the fellowship director and radiation oncology proton staff. Three letters of recommendation from their residency program director and faculty members will be required for review. Fellows will be offered a training fellowship position based upon the assessments of the fellowship director, the radiation oncology proton staff, and the Radiation Oncology Senior Executive Committee. The selection criteria will include the qualifications of the trainee as evidenced by performance during residency training, publication record, level of interest, and anticipated level of clinical and academic performance by the fellow. Partners and Harvard guidelines for diversity consideration will be followed.
Prior to the initiation of the fellowship position, fellows must have completed an approved Radiation Oncology Residency Program. For trainees from outside the United States, successful completion of USLME 1, 2, and 3 and acquisition of at least a limited medical license in Massachusetts are required for their credentialing and for their contract to be in force.
Please submit all inquiries to:
Amanda E. Maidment
Education Program Coordinator
Massachusetts General Hospital
55 Fruit Street
Lunder Building, LL2
Boston, MA. 02114