Two Weeks Into Radiation Oncology

Since I matched to radiation oncology residency over 15 months ago, I spent a whole 20 days of my PGY-1 year in the specialty. Thanks to the general clinical off-service first year, it's not uncommon for residents to see little to none of their own specialty until PGY-2. And that's tough. I secretly enjoyed a lot of my off-service rotations more than I was willing to let on and can't say that I didn't wonder whether I'd still like rad onc as much as I'd thought I did when I finally got back to it. More so, I worried about whether I'd enjoy doing the stuff that rad oncs actually do, rather than the half-day-clinic-home-by-4 pm impression I got as a medical student.

Now having spent the first two weeks of my PGY-2 year in radiation oncology, I think I can say pretty confidently that I'm in the right specialty. And that's more of a relief than you can imagine.

and I have a desk now which makes me so happy (I know, our residents' room is overdue for some tidying)

That's not to say that the past two weeks have been stress-free. There's a steep learning curve in radiation oncology because it's unlike anything you see in medical school or on off-service residency rotations. Alongside learning about oncology, I'll get to take courses in radiobiology and medical physics. On the practical side of things, I'll learn how to plan out ionizing radiation fields and prescribe appropriate radiation doses.

To be honest, I've spent the majority of this rotation feeling in over my head. And I'm sure that won't end anytime soon. I'm clueless when asked how many centigray I would prescribe or whether we should use two or four radiation fields...sometimes in rounds I don't even know whether a patient requires radiation at all. I've only just figured out what kinds of radiation machines we have in the building -- but couldn't tell you how they work or when we'd use VMAT over 3DCRT. Speaking of which, I'm also trying to learn All The Acronyms. I spend breast cancer rounds hoping that I won't say a made-up chemo acronym when they ask me what should be prescribed (the chemo regimens have names like FEC-D...and sometimes the "C" means carboplatin instead of cyclophosphamide, just to throw you off).

one of many things I don't know -- how to contour axillary lymph nodes (according to the RTOG atlas)

As much as this rant may resemble complaining, I'm really not. At least once a day I have a this-is-so-cool-I-can't-believe-I-get-to-do-this moment -- most recently when taking a closer look at the multileaf collimetor used to shape the radiation beam on one of the machines (nerd alert). I realize how lucky I am to be getting paid to learn all of this fascinating stuff and I couldn't be happier with the centre I'm at and the staff and residents I get to work with.

this poster is up in the hallway at work (and helped reassure me that I'm in the right residency program)

I think it's easy in residency to get pushed into trying to run before you can walk...all part of the whole learning-by-getting-thrown-into-the-deep-end philosophy. While I don't doubt that it works, I do sometimes wonder if it's the best way to go about learning something. I think I approached learning guitar in a similar fashion: I got bored with theory and chords and skipped ahead to trying to learn songs from YouTube videos. The result? I play the chords (couldn't tell you their names) with the wrong fingers. I don't even hold my guitar the right way. It's really bad and while I don't think things will go quite as wrong with rad onc, I know I'm already getting ahead of myself by trying to do radiation plans before I've learned the CT anatomy or the RTOG contouring guidelines...or have even had my orientation to the planning software.

radiation planning and Munchies for dinner -- probably a preview of the rest of residency

It's stressful, but you've got to roll with what staff tell you to do and trust that things will make more sense once you've filled in your knowledge gaps (a big one in my case being medical physics...as well as all of the studies that we base radiation treatment on, which I have yet to read). I think most important is admitting what you don't know. I feel a bit embarrassed asking my staff things that I figure I should know by PGY-2, but really residency is the time to ask questions. If I don't understand the basics now, it'll only get harder to admit that I don't know them two years from now. So, medical students, it does no good to pretend that you can see the JVP or hear heart murmurs when you can't (I can't be the only one who is guilty here) -- hopefully you'll figure out sooner than I did that no one will judge you for not knowing something (okay that's not entirely true, but those attendings who do fault you are probably surgeons probably need a reminder of what it's like to be at our stage).

Overall I think I'm where I want to be right now and that's reassuring to realize, coming out of the state of flux that is clerkship and PGY-1. I guess eventually I'll move through the old "unconsciously incompetent -> consciously incompetent (yup!) -> consciously competent -> unconsciously competent" spectrum. Forget unconsciously competent, I'd be happy to end up a humble consciously competent radiation oncologist in four years' time.