At the start of the program, residents are provided with a residency training schedule, called the qualification card, that they are expected to follow for the duration of their two year training. The qualification card provides an overview of each clinical rotation, the rotation duration, learning objectives, reading materials, and required assignments for each rotation as well as for the program as a whole. Each task in the qualification card requires a sign-off by the supervising physicist in order to consider it complete.
During the first year, the physics resident attends didactic lectures, conferences, and participates directly in the clinic through a series of structured rotations. The resident works closely with staff physicists and dosimetrists to observe and participate in conventional and IMRT treatment planning, image acquisition, on-board imaging, fusion, registration, dose calculations, design and fabrication of patient treatment aids, treatment machine calibrations, patient and phantom dose measurements, quality assurance procedures, brachytherapy procedures, and other physical and technical tasks performed in the clinic. They will also be responsible for several clinical projects and reports to help strengthen their understanding of the clinic. During this time, the resident should develop basic radiation oncology physics skills and also should develop an overall understanding of the radiation oncology physicist’s and dosimetrist’s role in the clinic.
At the beginning of the second year, the successful physics resident is given more responsibility (but always under the direct supervision of a physics staff member) and expected to function as a junior physicist. During the second year, the resident should develop confidence and continue the development of the necessary skills and experience to be prepared for independent clinical physics practice. By the completion of year two, the resident is expected to be able to perform all radiation oncology physics functions, including full calibration of treatment machines, checks of dosimetry work, radiation safety procures, clinical consultations, and patient-related dosimetry.
Our program is organized into 10 structured rotations to ensure the vast breadth of radiation oncology topics is covered in two years. Each rotation is mentored by a staff physicist who will help guide the resident through various aspects of the rotation, monitor the resident’s progress through weekly meetings, and serve as a consultant for their questions. The mentor will also coordinate the activities of the resident with secondary preceptors and will be responsible for ensuring that the resident gets an opportunity to complete all the required competencies during their rotation.
During any given rotation, a resident may also work closely or interact with numerous physicists and staff at any given time in order to gain clinical insight or experience. Successful completion of each rotation includes completion of all the assigned tasks in the qualification card for that rotation, and passing the end-of-rotation comprehensive oral examination. The rotations are offered in the following chronological order:
ORIENTATION, SAFETY, AND EXTERNAL BEAM 1
Duration: 3 months
In this rotation, residents are introduced to staff, resources, and procedures at the Department of Radiation Oncology. The External Beam 1 rotation is meant for the resident to gain experience with basic conformal 3D radiotherapy planning and familiarization with patient immobilization and setup. Residents will observe the dosimetrists during the treatment planning process of multiple anatomical sites. Once proficiency is demonstrated in planning, the resident is then expected to contribute to the clinical workload for simple 3D plans. The rotation also covers quality assurance procedures for both equipment and patient charts.
Duration: 3 months
The rotation is structured to provide the resident with knowledge of brachytherapy basics and applications, including radioactive decay, source characteristics, calculation of dose distributions, systems of implant dosimetry, and implantation techniques. Residents will participate in all HDR brachytherapy procedures that take place during the rotation, including simulation, treatment planning, and delivery. The brachytherapy rotation also covers quality assurance procedures for both equipment and patient charts, brachytherapy treatment planning, and brachytherapy delivery. Residents will also be involved in any special brachytherapy procedures that might take place throughout the year even if they are not on the rotation at that time.
EXTERNAL BEAM 2
Duration: 2 months
In this rotation, residents are introduced to more complicated aspects of dosimetry, focusing on IMRT and VMAT techniques. Residents will be introduced to optimization, critical organ doses, typical dose-volume constraints, dose calculation algorithms, and the basics of imaging for IMRT/VMAT. Residents will observe the dosimetrists during the IMRT/VMAT treatment planning process of multiple anatomical sites and then plan a number of practice cases. Once proficiency is demonstrated, the resident will contribute to the clinical workload for IMRT/VMAT planning, performing all the associated dosimetrist duties, including CT simulation import, image registration, contouring, and R&V documentation.
Duration: 2 months
The stereotactic rotation covers linac-based radiosurgery and stereotactic body radiation therapy procedures, including motion management techniques and advanced image guidance. The resident is expected to observe dosimetrists and then participate in stereotactic planning and treatment. The resident will also learn QA procedures for the Varian Edge linac and perform several practical end-to-end clinical projects related to our radiosurgery program.
MRI - GUIDED RADIATION THERAPY
Duration: 2 months
The rotation introduces the resident to MRI-guided radiation therapy on the ViewRay MRIdian linac. This is the only rotation that takes place at the Health Central satellite location. The resident will learn about basic MRI physics, MRI safety, MRI-based image guidance for patient setup and adaptive treatment, motion management strategies, ViewRay treatment planning, and the adaptive planning workflow. The resident will also learn how to perform QA on the ViewRay system, including IMRT QA and linac QA. The rotation is scheduled so that it occurs when annual QA is due for the ViewRay MRIdian, ensuring that the resident can observe and assist in the annual QA.
Duration: 2 months
The Tomotherapy rotation exposes the resident to all aspects of the Tomotherapy system, including treatment planning, linac components, MVCT image guidance, and patient treatments. The resident will observe the dosimetrist and learn how to use the Tomotherapy planning system. Once proficiency is demonstrated, the resident will be expected to plan patient cases for a number of anatomic sites. The resident will also be exposed to all aspects of the Tomotherapy QA program, including patient-specific and linac QA. They will observe and assist in the annual QA as well.
EXTERNAL BEAM 3
Duration: 3 months
The third external beam rotation will build upon the first and second rotations, using the knowledge gained previously to study the overall process of commissioning a linac and treatment planning system. If there are linac commissioning opportunities available, the resident will be actively involved in the process and the rotation structured around its inclusion. The rotation will cover CT simulator QA, annual linac QA, and treatment planning system QA. Several clinical projects are used in this rotation to teach the resident about clinical duties not commonly encountered in the everyday routine of a physicist, including topics, such as radiation shielding design, TBI, and TSET. Since TSET is occasionally done at Orlando Health, the resident will actually develop a TSET plan and deliver it on the linac dedicated to the procedure. The TBI program is currently being commissioned at Orlando Health, allowing the resident to complete a similar type of TBI clinical project as well.
Duration: 2 months
During the proton therapy rotation, the resident will be given an overview of proton therapy physics and treatment techniques. The resident will be fully immersed in our proton therapy clinic which includes a Mevion S250 system. The resident is expected to participate in patient simulation, immobilization, clinical proton treatment planning, and all aspects of QA (daily, monthly, annual, and patient-specific) on the Mevion S250 system. The rotation is specifically designed to occur when the annual QA is due for the Mevion unit, ensuring that the resident will be actively involved in this process.
Duration: 2 months
The rotation is designed to build upon the first brachytherapy rotation, focusing on more advanced concepts like treatment planning system QA and dose calculation algorithms. The rotation will also serve to cover LDR brachytherapy physics and techniques. The resident will learn about LDR prostate seed implant procedures, including the selection of radioisotopes, ordering of radioactive seeds, treatment planning, and the associated QA and radiation safety procedures that are required for LDR implants performed at Orlando Health. Occasionally, LDR head-and-neck implants are performed at our institution. The resident will be involved in these special procedures even if they don’t occur during their brachytherapy rotation time frame. The rotation will also cover Y-90 used for liver tumors, a procedure commonly done at Orlando Health using either SIR-Spheres or TheraSpheres. The resident will be expected to contribute to the clinical workload of Y-90 procedures once competency is demonstrated.
EXTERNAL BEAM 4
Duration: 3 months
In this rotation (designed to be the last rotation before graduation), the resident is expected to take on more independent clinical tasks, such as initial chart checks and junior on-call physicist responsibilities under the supervision of a staff physicist. This rotation will provide the resident with the fundamental knowledge and practical training for proficiency with day-to-day clinical operations as an on-call physicist. This rotation will teach the resident how to troubleshoot machine issues and it will help build their confidence in clinical problem solving. This rotation also allows a resident to complete any competencies from other rotations that remain incomplete. If the resident is ahead of schedule, they can use this time to study for the ABR certification examination, perform a job search, or focus on special topics of their choice.
In additional to the clinical rotations, the resident will receive training through didactic lectures in order to enhance the resident’s technical and clinical knowledge. Residents are required to attend weekly physics residency seminars given by program staff, physicians, and residents. The seminars are meant to be a time for discussion and learning of the given topic. Residents are required to give one of the weekly physics seminars each quarter during the residency (total of eight), on a topic of their choice or as assigned by their rotation advisor. The objective of this requirement is to enhance the resident’s presentation skills, as well as provide a forum for oral questioning in order to help prepare the resident for board examinations. In addition, the resident is expected to offer the annual radiation in-service seminar to the therapists and nursing staff.
Residents are expected to participate in all department conferences attended by the physics staff. The purpose of this requirement is to immerse the resident in the world of clinical physics as well as the workings of the clinic. The quarterly radiation oncology department meeting and monthly physics meetings are mandatory and cover more operational topics for physicists. Residents are also invited to attend monthly physics quality meetings to discuss quality improvement projects and review changes in physics policies and procedures.
The cancer center holds weekly conferences for medical oncology fellows. Residents are encouraged to attend when the topic is related to radiation oncology. Residents also participate in department conferences, including peer review, radiation oncology chart rounds, visiting professors' lectures, vendor demonstrations, in-service training sessions, radiation safety in-services, and weekly physics research meetings. Residents are assigned to facilitate physician peer review and chart rounds for one week every eight weeks. Regular lectures and meetings include:
- Monthly physics staff meeting
- Quarterly department staff meeting
- Monthly physics quality committee meeting
- Twice-weekly peer review
- Weekly radiation oncology chart rounds
- Weekly physics residency seminar
- Weekly medical oncology lecture series
- Weekly physics research meeting
Several written reports are required within each rotation on clinic and physics-related topics to enhance the residents' understanding of the topic and clinic workflow. These reports are reviewed and discussed with their rotation advisor or a staff physicist in order to make sure they understand the fundamental aspects that should be gleaned from the report topic. Examples of report topics include linear accelerator system components, treatment planning site-specific reports, shadowing reports, linac shielding evaluation, OSLD’s, TBI, and radiation therapy with the CyberKnife and GammaKnife system.
INDEPENDENT CLINICAL PROJECTS
In parallel with the clinical assignments, the resident is assigned projects that cover topics which are not routinely encountered in daily clinic duties (e.g. linac acceptance and commissioning, treatment planning system commissioning and beam modeling, etc.). These are designed to be major projects that require longer periods to complete (i.e., 1-2 months). These projects are sorted by rotation in the qualification card and have specific goals and end points, as well as assigned readings (e.g. AAPM Task Group reports, journal articles, etc.) that are detailed in the qualification card.
The resident is assigned to a mentor for the duration of each project, which is usually the advisor for the rotation in which the project is assigned. These projects are designed to be completed outside of assigned clinical duties. The resident is expected to independently perform all tasks required to complete the project. Throughout the duration of the project, the mentor is available for questions and additional instructions.
Even though these clinical projects are sorted in the qualification card by rotation, the resident is not required to complete it during this specific time frame. For instance, the linear accelerator commissioning project may and should be satisfied if this event takes place during the resident’s two year span, regardless of which rotation the resident is in at the time. Upon completion of the project, the resident submits a written report documenting all tasks completed and also reviews their findings with the assigned project mentor.
INTEGRATED CLINICAL ACTIVITIES
Physics residents have the opportunity to contribute to clinical services in a variety of areas after the resident has demonstrated competency. Many of the duties are only assigned while the resident is on that rotation. Examples of resident duties include:
- External beam clinical treatment planning
- In-vivo dosimetry
- CT simulator quality assurance
- Monthly and annual quality assurance of linear accelerators
- Patient-specific IMRT quality assurance (shared rotation with QA Physics Assistants)
- HDR afterloader quality assurance and source exchanges
- Brachytherapy clinical patient planning
- Various clinical projects, including device and procedure commissioning measurements
- Radioactive source shipment and receipt
- Radiation detector calibration and cross-calibration
- Weekly chart checks and end-of-treatment chart checks
- Quasi-independent clinical coverage and troubleshooting
- Leading departmental chart rounds and peer review
- Conduct and organize physics weekly seminar series (duty of the junior physicist)
In addition to the clinical rotations and independent projects, the resident participates in any clinically relevant major projects that may arise that are not specifically covered in the clinical and project assignments or the qualification card. Resident involvement in these additional projects will not detract from the clinical assignments and independent project requirements described above. These major projects include, but are not limited to, the following:
- Acceptance testing and commissioning of new equipment
- Testing and implementation of new treatment techniques
- Implementation of new equipment and procedures
- Clinically related development projects
- Evaluation of potentially new clinical technologies
Some examples of recently completed additional duties by our residents include commissioning measurements for iPlan Elements on the Edge linac, commissioning of Eclipse Brachytherapy treatment planning system, commissioning of the new upgrade for the ViewRay MRIdian linac, and acceptance and commissioning of the Varian TrueBeam linac.
Second-year residents are involved in the training of first-year residents as allowed by clinical and project schedules. This role is intended to develop the resident's supervisory skills within a clinical setting. The second-year resident does not formally oversee clinical duties assigned to the first-year resident, but assists in development of skills necessary for completion of projects assigned to the first-year resident (e.g., set-up and operation of scanning systems, operation of linear accelerators, IMRT QA, etc.).
OPTIONAL RESEARCH PROJECT
While research is not a requirement of this program, there are numerous opportunities for working on clinical development projects. Weekly research meetings are conducted every Friday in our department and the resident is invited to attend. These meetings are commonly attended by physician faculty, staff physicists, and vendors involved with the hospital’s current research projects. The resident is allowed to participate in clinical development projects if they choose to do so and are in good standing with respect to program requirements.