There has been a progressive shift toward adopting an integrated residency program structure among many specialties that had traditionally required a separate internship year;¹ however, this element of the radiation oncology training landscape has remained largely unchanged. Although a small number of radiation oncology programs have a linked intern year and are thus considered categorical, most begin at the PGY-2 level, requiring applicants to apply to internships separately. While the transition toward integrated internships has been gradual and largely program-dependent in many specialties, some recent examples of a consolidated effort link the PGY-1 year with advanced training. For example, the Accreditation Council for Graduate Medical Education (ACGME) has requested all ophthalmology residency programs become integrated or joint by July 2023.² There are several potential advantages to similarly implementing a universal integrated program structure in radiation oncology.

Preliminary year training is currently heterogenous among radiation oncology residents, who have the option to complete their internship in any number of specialties including internal medicine, family medicine, surgery, obstetrics and gynecology, pediatrics, or with a transitional year.² An integrated program structure could introduce standardization across PGY-1 training and, more importantly, could be leveraged to tailor the first year of residency toward clinical experiences considered valuable for radiation oncology. For example, surgical exposure and gross anatomy education have been identified as valuable competencies for radiation oncology but are not typically included in the standard residency curriculum.^3-6 Similarly, many radiation oncology residents have reported a need for dedicated diagnostic radiology training during residency.⁷ A PGY-1 year tailored specifically for radiation oncology could provide the opportunity for formal education in these areas. It should be noted that a minimum of 9 months of direct patient care during the preliminary year is required by the ACGME;² still, it is likely that many of the rotations beneficial for a career in radiation oncology (such as surgical oncology, ENT, medical oncology, etc.) would fall under this heading.

One might also consider the possibility of earlier introduction to radiation oncology during the intern year. For example, PGY-2 ophthalmology residents who completed ophthalmology training time during their internship reported greater preparedness in formulating ophthalmic diagnoses and performing the ophthalmic exam.⁸ The ACGME currently allows for up to 3 months of radiation oncology rotations during the preliminary year, although typically only transitional year programs include the substantial elective time needed to capitalize on this (even then, not all programs have an affiliated radiation oncology department and many also have their own requirements for how elective time can be spent).^2,9 Standardizing radiation oncology exposure during the PGY-1 year may be advantageous, especially with the continued emergence of newer treatment modalities.

Additionally, completing the preliminary year at the same institution as radiation oncology residency could facilitate earlier mentorship and research opportunities. Given the longitudinal nature of clinical research, such a program structure may enhance productivity while allowing residents to explore different research interests ahead of their dedicated research blocks—something that would be particularly beneficial in residencies with less dedicated nonclinical time.¹⁰ Moreover, a linked PGY-1 year would also allow for earlier integration into the hospital system where one’s advanced training will be completed. Prior familiarity with the electronic medical record (EMR), hospital layout, and other departments and services one will be working with and consulting on would likely ease the immense transition from the PGY-1 to PGY-2 year.

It should also be highlighted that linking the intern year with advanced training would help reduce the significant financial and logistical burden associated with applying to residency. Medical students currently spend hundreds—even thousands—of dollars on residency applications;¹¹ for students pursuing radiation oncology, this includes the cost of additional applications for separate internship programs. While the switch to virtual interviews in the wake of the COVID-19 pandemic has helped mitigate the substantial overall cost of the residency application process, the cost of the application itself should not be ignored—especially if some form of in-person interviewing eventually resumes. Reducing the overall number of applications necessary to submit would be a step closer to decreasing the significant economic barriers inherent in this process. Additionally, the cost of potentially moving twice—once for internship and again for advanced training—should be considered as well.

Some advantages to maintaining a residency structure with separate internship and advanced training are worth noting. First, while there is likely an overall benefit to introducing standardization across the PGY-1 year, the current flexibility in choice of internship type allows residents to tailor their training to align with their clinical interests. Additionally, residents may capitalize on the geographic flexibility of a non-integrated internship to explore a different region of the country or spend a year close to home or family. Moreover, many argue that a full year of internal medicine or surgery provides the opportunity to build broad clinical skills before embarking on a highly specialized career trajectory. Still, these factors should be weighed against the many educational, financial, and logistical benefits of transitioning toward an integrated program structure in radiation oncology similar to that of many other specialties.

REFERENCES

1. Pfeifer CM. Evolution of the preliminary clinical year and the case for a categorical diagnostic radiology residency. J Am Coll Radiol. 2016;13(7):842-848.
2. Accreditation Council for Graduate Medical Education. ACGME specialties requiring a preliminary year. July 1, 2020. Accessed October 9, 2021. https://www.acgme.org/globalassets/pfassets/programresources/pgy1requirements.pdf
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11. Association of American Medical Colleges. The cost of applying for medical residency. September 20, 2021. Accessed October 29, 2021. https://students-residents.aamc.org/financial-aid-resources/cost-applying-medical-residency