Frameworks for Radiation Oncology Global Health Initiatives in US Residency Programs.

PURPOSE: To understand trends, pathways, and experiences and to establish a framework for radiation oncology (RO) programs interested in developing global health (GH) initiatives.
METHODS: An in-depth interview was conducted of all US RO programs with established GH initiatives. Programs were identified by reviewing results of the 2018 Association of Residents in Radiation Oncology Global Health Resident Survey and individualized outreach to screen for additional programs meeting the following criteria: (1) active resident involvement in RO-specific GH opportunities, (2) active faculty involvement in these initiatives, and (3) department chair or program director awareness and support for ongoing opportunities. Among 88 residency programs, 11 were identified. Standardized questions explored the type of initiative, planning, staff and resident involvement, challenges, components to success, and history of programs through December 2018.
RESULTS: Between 2010 and 2018, 11 programs started initiatives. Total resident participants ranged from one to 13 (median = 3) in each program's history. Initiatives spanned education (n = 9 [82%]), clinical mentorship (73%), innovative technology (55%), bilateral hosting programs (45%), clinical development and equipment (45%), promotion of local research (36%), clinical care (36%), industry partnerships (27%), and remote tumor board (18%). Faculty involvement included radiation oncologists (91%), medical physicists (55%), and non-RO department faculty (27%). Six programs (55%) had faculty with prior GH experience. Four (36%) programs reported medical student involvement in projects. Barriers included international communication (36%), time for faculty (18%), funding (9%), and legal (9%) concerns. Commonest components of success included fostering relationships with international sites and identifying needs before solutions.
CONCLUSION: RO GH initiatives were reported as positive, educational, and feasible across 11 US residency programs. Growth is expected, representing opportunities for innovation and service among US programs.

INTRODUCTION

Over the past 2 decades, medical training has evolved with global health (GH) pathways now available in 90% of US medical schools.[1,2] This growth has spurred the development of postgraduate training in GH as well, with several programs focusing on areas such as infectious disease, primary care, and maternal and child health. Reported advantages from focused study in GH include increased medical knowledge,[3] improved diagnostic skills,[4] enhanced cultural humility[5]; increased awareness of social determinants of health, and greater understanding of resource usage.[4] Furthermore, trainees who pursue GH education feel better prepared to engage in an increasingly connected global economy and respond to health system challenges.[6]

During this evolution, the field of global oncology has risen to prominence. Globally, cancer is a major source of morbidity and mortality with an estimated 18.1 million new cancer case diagnoses and 9.6 million cancer deaths in 2018.[7] To address this rising cancer burden, improvements in screening, diagnosis, and treatment are needed. Radiation therapy is a critical component of cancer treatment, comprising the standard of care for more than 50% of newly diagnosed cancers and an effective treatment modality for palliation in advanced disease. US residents in radiation oncology (RO) are increasingly seeking opportunities to become involved in GH during and beyond residency, and program directors wish to support this interest.[8,9]

However, across a backdrop of altruistic energy, there has been little guidance on how to implement new GH initiatives. Radiation oncologist trainees lack an organized network of GH faculty mentors, whereas program directors lack a blueprint for how to foster an interest in GH during residency.[8,9] As with all beginnings, there currently is a lack of relevant experience among radiation oncologists, lack of well-established pathways, and lack of cancer-specific GH faculty, even at centers where GH institutes have been established. To share information about existing GH programs and to help provide guidance to new programs, we performed a qualitative investigation of RO residency programs in the United States. Through this, we hope to empower further efforts that allow high-income country and low- and middle-income country (LMIC) collaboration to improve cancer care for patients in a time of great need.

METHODS

US RO residency programs with established GH initiatives were identified through the Association of Residents in Radiation Oncology (ARRO) and the 2018 ARRO Global Health Resident Survey.[9] Programs had to meet the following criteria for inclusion: (1) active resident involvement in RO-specific GH opportunities, (2) active faculty involvement in these initiatives, (3) department chair or program director awareness and support for ongoing opportunities, and (4) focus on LMIC. Among 88 residency programs, 11 were identified and invited for an in-depth 1- to 1.5-hour interview via teleconference. Institutional review board review for ethical approval was not required.

A semi-structured interview was conducted to learn frameworks of their RO GH programming, including the type of initiative, planning, staff and resident involvement, challenges, components to success, and history of the programs through December 2018. Correspondents included program directors or a point of contact identified by the program director who had direct involvement with their GH initiative. A set of standardized questions (Appendix, online only) was used to guide the conversation, and, if needed, follow-up e-mails were sent to clarify any missing points and ensure all standard questions were covered. Notes from interviews were saved with appended e-mail responses and analyzed as a group.

RESULTS

All 11 identified US RO residency programs with GH initiatives are listed in Table 1. Based on qualitative interviews, there were nine common themes for initiatives that appeared (1) clinical development and equipment, (2) clinical mentorship, (3) education, (4) remote tumor board, (5) promotion of local research, (6) industry partnership, (7) clinical care, (8) innovative technology, and (9) bilateral international hosting programs. Programs had sites with GH initiatives in Africa, Latin America, and Asia. A map of connections is shown in Figure 1.

TABLE 1

US Residency Program Global Health Initiatives

FIG 1

World map of US radiation oncology residency program–based initiatives from 2010 to 2018.

GH initiatives began in 2010, 2011, 2012, 2015 (n = 2), 2017 (n = 4), and 2018 (n = 2). The number of total resident participants per program ranged from one to 13 (median = 3) over each program’s history. Program initiatives spanned the following categories: education (n = 9 [82%]), clinical mentorship (73%), innovative technology (55%), bilateral hosting programs (45%), clinical development and equipment (45%), promotion of local research (36%), clinical care (36%), industry partnerships (27%), and remote tumor board (18%). Examples of different initiatives are displayed in Table 2.

TABLE 2

Examples of Different Types of GH Initiatives

Faculty mentors for resident GH initiatives included radiation oncologists in 10 programs (91%), medical physicists in six (55%), and non-RO department faculty (eg, medical oncology, gynecology-oncology, and so on) in three (27%). Only six programs (55%) had faculty with prior GH experience. Four (36%) programs reported medical student involvement in projects. Four (36%) programs were built upon existing institutional connections, four (36%) started with resident or medical student travel to the site (either during the planning process or after the return of the trainee), one (9%) spurred from an existing staff family connection, one (9%) arose from being contacted by the LMIC center, and one (9%) was planned from the beginning with RO department leadership.

A summary of the logistics for GH experiences during residency is shown in Table 3. Most programs (73%) required resident time preparation, half of the residents (45%) participated in their final 2 years of residency, and most (82%) were able to obtain 50%-100% funding from their RO department for their projects, including travel. Of six cases where outside funding was required, four (67%) obtained support from their university's GH institute, one (17%) from a clinical innovation grant, and one (17%) from the ARRO Global Health Scholars Program.[10]

TABLE 3

Logistical Experiences With Global Health Initiatives for Residency Programs

The current GH program was the same as originally planned for five programs (45%), somewhat similar for four (36%), and not the same for two (18%). Nearly all (91%) programs indicated that their initiatives have grown. All (100%) stated that there is perceived benefit at both home and international institutions and foresee growth. Seven (64%) focused on the same location(s) since inception, whereas four (36%) stated they expanded their GH efforts to involve new locations over time.

Barriers impeding initiatives included international communication (36%), time for faculty (18%), funding (9%), and legal (9%) concerns. Three (27%) programs adjusted their project scope based on legal limitations. Institutional permission, time for residents, and safety were not reported as barriers by any program. These results are summarized in Figure 2.

FIG 2

Barriers in implementing global health initiatives for residency programs.

Each program described the most important factor for success in their GH effort for other programs to learn from. Responses were analyzed and fit into one or more of these common categories: (1) developing lasting relationships (with global partner), (2) identifying partner institution's needs, (3) funding for residents, (4) time for residents, (5) achievable metrics and sustainability, (6) faculty for long-term involvement, and (7) department leadership support. Developing lasting relationships and identifying partner needs were the most recognized factors for success, as shown in Figure 3.

FIG 3

Most important factors for implementing global health initiatives for residency programs.

DISCUSSION

GH programs appear to be increasing over time with over half of new programs emerging in the last 2 years. Initiatives spanned many categories, with the majority of programs incorporating education and clinical mentorship in their activities. About half of programs involved innovative technology, bilateral hosting programs, and clinical development and equipment. Less frequently, programs included the promotion of local research, involvement in clinical care, industry partnerships, and remote tumor board. As initiatives grew with their first resident involved, over time there was a trend toward more resident involvement and greater scope of activities. The collective experiences establish an early framework in RO for approaching GH at the program level.

How are GH partners identified? The most common geographic region for initiatives was in Africa, with 8 of 11 programs focusing efforts there. Among other regions in the world, two programs had a focus in Latin America, one in India, and one in Southeast Asia. In general, the following strategies exist to create GH opportunities for residents: establish a new relationship with a single RO department, build upon an existing institutional partnership (may be multidisciplinary), or create pathways with multiple institutions to fit resident interests. The following examples illustrate each approach:

Establish a new relationship with a single RO department.

University of California Los Angeles/Los Barretos Hospital de Amor.

A University of California Los Angeles (UCLA) RO resident befriended a Brazilian physician at the American Society for Radiation Oncology (ASTRO) national conference. He later applied for the ARRO GH travel award, traveled to Brazil for one month during residency, and through his visit started a twinning relationship between UCLA and the second largest cancer hospital in Brazil. UCLA now hosts an annual conference each year with its partner site in Brazil. This started with multiple faculty in RO and now includes several other UCLA departments for multidisciplinary cancer collaboration.[11]

Medical College of Wisconsin/Christian Medical College.

Beginning with a familial tie between a radiation oncologist at Medical College of Wisconsin (MCW) and a hospital in India, the two institutions began talking about collaboration in 2013. This was formalized in 2017. The program is evolving and has grown into a partnership involving many departments (RO, medical oncology, gynecologic oncology, and so on). It permits an exchange of clinicians from India to MCW and vice versa, and there is a longitudinal relationship including residents through Zoom conference calls in Grand Rounds fashion.

MD Anderson Center/Cancer Center/Cancer Diseases Hospital.

The department was contacted directly by a resident-teaching hospital in Zambia seeking support. This conversation led to the development of an institutional twinning relationship that has focused on education initiatives involving residents, using remote engagements to learn about realities and challenges of radiotherapy in the region and then using that to inform educational projects in conjunction with supportive faculty. An example is a 1-week radiobiology course designed by a resident for LMIC settings that can be replicated and shared with other centers.

Others that began with new single-department partnerships include Duke/Bugando Medical Center and Stanford/Kenyatta National Hospital and Ocean Road Cancer Institute.

Build upon an existing institutional partnership.

Harvard University/University of Botswana, Botswana Harvard AIDS Institute.

The partnership developed out of an existing relationship in Botswana based on HIV-AIDS work, with an idea to expand to RO. Harvard established a weekly multidisciplinary tumor board through its Botswana Oncology Global Outreach initiative beginning in 2012, which helped identify challenges and has been the gateway for many other collaborations and bidirectional exchange trips. It now involves numerous staff from RO as well as other departments and has established extramural funding pathways.[12]

University of Pennsylvania/Princess Marina Hospital, University of Botswana.

UPenn had a very well-established partnership with a university hospital in Botswana and sent medical students and residents in many different specialties.[13] With full institutional support, UPenn established a full-time–supported RO faculty living and working internationally for GH work since 2014. With this strong connection, there is now a direct link for research, education, and advancement of clinic care that extends regionally from the partner site. For RO rotations, 13 residents, including 6 from outside UPenn, have rotated at this host site.

Emory University/Black Lion Hospital.

The RO department at Emory University was interested in starting a GH initiative, and its Center for Global Health identified an existing memorandum of agreement with a hospital in Ethiopia. After speaking with the hospital and learning its needs, an Emory resident worked with the faculty to develop an off-line head- and neck-contouring module. This helped Ethiopian RO residents achieve significant improvements in their abilities.[14] The program was so successful that it has now been implemented at Emory's own residency program for training new residents.

Others that have built upon existing institutional partnerships include University of California San Francisco (UCSF)/Ocean Road Cancer Institute. (An advantage of multidisciplinary partnership with one center is a better 360° understanding of the health system, barriers, and opportunities. By concentrating efforts from multiple departments into one center, efforts can learn from each other and be streamlined for a wholistic approach within the center.

Open pathways with multiple institutions.

University of California San Diego.

The department established an international rotation program for medical and physics residents, who are offered the chance to travel for 1 month during their residency to an international site of their choice. This includes both high-income countries and LMIC globally. Department leadership perceives several benefits of this program, and most residents participate in this opportunity during their residency.[15]

Vanderbilt University.

A Vanderbilt medical student first traveled and established relationships with several clinics in Latin America, then introduced the concept of remote engagements in real time with multiple institutions sharing similar educational needs. Now connections exist for other medical students, residents, and faculty to connect with these clinics simultaneously.[16,17] A telehealth curriculum is delivered as a series of video conferences with volunteer support from faculty educators at Vanderbilt and other institutions. The pool of educators is organized by Rayos Contra Cancer (RCC),[18] a nonprofit organization that designs outreach opportunities in RO for practitioners in limited-resource settings. Vanderbilt Medical School remains an RCC hub for medical students to build programs with faculty mentorship.

What do faculty roles look like? The engagement of faculty was important for each program's success. Primary faculty, including radiation oncologists, medical physicists, or other specialists, were able to facilitate continuity and the entryway for residents in projects catered to their level of experience. Previous GH experience was not necessary as nearly half of departments stated no prior GH experience among faculty. Multiple approaches were identified to engender faculty involvement. Several residents have presented their GH experience to the entire department, which subsequently led to faculty interest. Some faculty have participated in remote educational engagements with partner centers. Some departments, such as UCSF, have hosted monthly global oncology seminars that have been attended by residents, fellows, faculty, and outside speakers. Lastly, UPenn supports a full-time GH RO faculty. Strong support from department leadership was among the most important factors mentioned for programs with GH.

Can outside organizations help new programs? In some cases, RO may serve as the link between institutions for further collaboration in neighboring disciplines, collaboration with industry, or partnership with supportive for-profit organizations and non-profit organizations (NGOs). With many institutions and organizations currently interested to support new initiatives, the landscape for GH in RO is ripe for synergy. Institutions can partner by supporting new initiatives or by expanding upon existing work.

NGOs can identify needs and contact academic institutions for possible support. This was the case for an RO program in Kenya, in which RAD-AID NGO identified a need for help with radiotherapy development and contacted Stanford, subsequently catalyzing the start of an initiative involving mentorship and education. Industry can also lend support for new initiatives, as Vanderbilt received assistance with establishing contacts in Latin America for its initiative, and Emory received support for the design and implementation of an educational module to aid with head-and-neck contouring accuracy. Additionally, the International Atomic Energy Agency (IAEA) funds residents for 2-3 months to work with them on projects in underserved regions, and MD Anderson has had two residents successfully get IAEA internships in Africa.

What barriers should be anticipated, and what successes can we learn from? Programs shared their greatest barriers and components for success. Surprisingly, most programs did not report funding, resident and/or faculty time, safety, and legal concerns as barriers to implementation. This could be related to selection bias, wherein only successful programs were interviewed who had adequate funding and support of resident and/or faculty time or whose initiatives lacked intensive financial or time requirements. Residents who traveled felt safe visiting foreign collaborating centers, and project proposals were generally received with enthusiastic support and flexibility from foreign partners. Communication was the most common barrier identified, reported by 4 of 11 programs.

The ability to communicate reliably is an important consideration in GH work. Today, improved internet connectivity allows smooth texting, e-mail, and phone and video calls. For live interactions, time zone differences must be taken into account and clearly communicated, especially during daylight savings time transitions. Avenues of communication and collaboration will likely improve further as technologies evolve for remote peer review, quality assurance, treatment planning, and other virtual supportive environments.

Another dimension of communication is language. This could be one reason that less US collaboration has been observed in Latin America, Asia, Oceania, and the Middle East. An ASTRO survey demonstrates increasing diversity in the US RO workforce of up to 30.2% non-White members,[19] although a gap still exists between our field and others in medicine.[20] Residents, faculty, medical students, and other supporters fluent and experienced in other languages and regions can be valuable to GH programs. Same-language interactions create a cultural connection that may strengthen working relationships and help new initiatives succeed.[21,22]

Overall, developing lasting relationships and identifying partner institution needs were most recommended for success. One program advised, “Ideas for the best collaborations will come naturally through engagement, discussion, curiosity, and open exploration… listen to what the actual problems are, and then build solutions based on real problems.” Another program stated, “If you want to get something off the ground, ask what they want, not what you think they need.” Both require humanistic communication and interaction, not just for logistics but also for friendship and connection.

This analysis is limited by depending on self-reporting. There is a risk of bias and no verification system for the reports from each institution. Additionally, future work exists to explore residency programs that tried but failed to establish a GH program by our predefined criteria. This would provide additional insight into barriers that have limited residency programs as there exist instances of single resident or faculty involvement that do not lead to the development of a departmental GH program.

In conclusion, in response to the rising cancer needs globally and interest in GH RO, there are a number of successful ways to establish program initiatives. Once established, the most important factors to facilitate a continued and enriching residency GH program are longitudinal involvement by at least one faculty member and high-quality communication with global partners. A program will be most successful if clinics of all resource levels feel heard, respected, appreciated, and seen as partner collaborators. In the end, we are all working together to help patients with cancer who come to us seeking care.