Journal of Cancer Education (2023) 38:813–820

https://doi.org/10.1007/s13187-022-02190-8

Evolution and Evaluation of a Structured Applied Physics Course

for Radiation Oncology and Radiation Physics Trainees
S. Babic1 · A. L. McNiven2 · A. Bezjak2 · J. M. Balogh3 · K. Mah2,3 · M. N. Tsao3

Accepted: 5 June 2022 / Published online: 28 June 2022

© The Author(s) under exclusive licence to American Association for Cancer Education 2022

Abstract
We sought to supplement medical physics textbook knowledge and clinical learning with case-based discussions. To our
knowledge, this is the first report on a structured combined applied physics curriculum for radiation oncology (RO) and
medical physics (MP) trainees. We reviewed our yearly applied physics course given from the years 2016–2021 inclusive.
The number of applied physics trainees ranged from 7 to 14 per year (2–9 RO and 3–6 MP residents per year). Each session
was taught by a pair of (RO and MP) faculty members. Twenty-nine case-based sessions were given yearly (2016 to 2019).
Because of the COVID-19 pandemic restrictions, the course was shortened to 8 case-based sessions in 2020 and 2021. For
the years 2016–2021, the mean and median teaching evaluation scores were 4.65 and 5, respectively (range 2–5), where 1
represents worse teaching quality and 5, the best teaching quality. For the year 2021, 2 questions relating to the video virtual
format (implemented due to the covid-19 pandemic), revealed consistent high scores with the mean and median responses
of 4.14 and 5, respectively (range 1–5). The results from the teaching evaluation scores indicate that the trainees highly
valued the teaching sessions and teachers. Our experience indicates that a case-based applied physics course was delivered
successfully with continued high teaching evaluation scores. A video virtual platform for an applied physics course could
be useful, especially for small programs without a structured applied physics curriculum.

Keywords Applied · Physics · Education

Introduction Several sources of applied physics learning are obtained

through textbooks [1–4] and hands-on clinical experience.
The practice of radiation oncology is built on a strong foun- This approach, however, is not structured and cannot reli-
dation of multi-professional interactions. A critical com- ably ensure that each trainee is competent in practice when
ponent for delivering high quality radiation oncology care applied physics knowledge and skills are crucial.
involves applying medical physics knowledge and skills to Based on the International Atomic Energy Agency
everyday practice. In order to build on the future for radia- (IAEA) recommendations on medical physics in Europe [5],
tion oncology, the curriculum for radiation oncology and close to 70% of medical physicists surveyed in 2015 cited
medical physics trainees relies, in part, on an effective lack of structured clinical training as an important issue.
applied physics course. The International Atomic Energy Agency has also specified
guidance on clinical training of medical physicists special-
izing in radiation oncology [6].
* M. N. Tsao The American Society for Radiation Oncology’s 2015
[email protected]
core physics curriculum for radiation oncology residents
1
Department of Radiation Oncology, University of Toronto, outlined the most important medical physics topics resi-
Carlo Fidani Regional Cancer Centre – Trillium Health dents are required to learn [7]. However, accredited radia-
Partners (Credit Valley Site), Mississauga, ON, Canada tion oncology training programs generally do not specifically
2
Department of Radiation Oncology, University of Toronto, outline detailed aspects relating to applied physics education
Princess Margaret Cancer Centre, Toronto, ON, Canada [8–11].
3
Department of Radiation Oncology, Odette Cancer Centre – We sought to supplement applied physics textbook learn-
Sunnybrook Health Sciences Centre, University of Toronto, ing and clinic learning with case-based discussions. These
2075 Bayview Ave, Toronto, ON, Canada

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814 Journal of Cancer Education (2023) 38:813–820

case-based discussions were guided by radiation oncology Trainees and teaching faculty were given the course syl-
and radiation physics faculty. This structure allowed for the labus, consisting of the course schedule and cases. Each
following pedagogical approaches: collaborative, integrative trainee was expected to prepare their answers for the cases
and inquiry. In this collaborative approach, students worked and discuss during the class sessions. The cases in the syl-
in small teams with the recognition that the students have labus were reviewed yearly by teaching faculty and adjusted
different levels of ability. As well, our students included both for updated clinical management and technological changes.
radiation oncology residents and radiation medical physics The RO physics curriculum required re-development in
residents. Students collaborated with one another to learn 2019–2020 due to the introduction of the new competency-
together. In the integrative approach, classroom education based curriculum, which necessitated completion of the
was taught with real-world applications. In the inquiry-based physics curriculum prior to the end of the Foundations of
approach, students were asked questions and were asked to Discipline stage of training in the Competence by Design
use reasoning and problem-solving skills to reach a solution. framework. Due to excellent feedback on the applied phys-
To our knowledge, this is the first report on a structured ics course by previous residents, the importance of applied
applied physics curriculum for radiation oncology and medi- knowledge and the additional benefits of inter-professional
cal physics trainees. education that the existing course offered, it was a priority
to include a version of the previous applied physics course in
the redesigned curriculum. The re-design included a planned
Methods and Materials reduction in the length of the applied physics course, as it
transitioned to a final module in the physics curriculum
We reviewed the recent 6 year applied physics teaching focused on Review and Integration of Physics Concepts in
experience (2016–2021) in a university-affiliated multi-hos- Clinical Cases (Applied Physics). Several topics were moved
pital site radiation oncology and medical physics accredited into one of the other 5 modules. Another key component
training program. The radiation oncology training program of the redesign was the weekly time allocated for physics,
is accredited through the Royal College of Physicians and which resulted in a change from a 1 h timeslot to a maximum
Surgeons of Canada. The medical physics training program 3 h timeslot.
is accredited through the Commission on Accreditation of The introduction of the new version of applied physics
Medical Physics Education Programs (CAMPEP). was further complicated due to the COVID-19 pandemic
The applied physics course was first developed in 1991 which necessitated a change in teaching format. Similar to
prior to the CAMPEP certification of the medical physics other teachers around the world [12, 13], our course coordi-
residency program. Although initially designed for radiation nators needed to adapt and change the way we taught applied
oncology residents, within 2 years, medical physics residents physics pre-pandemic by moving to a shortened virtual for-
joined the course. The course has been revised regularly to mat that would preserve high quality education and teacher-
incorporate evolving changes in practice, along with serial trainee interaction. Within this shortened format, some of
and exponential advances in radiation technology and com- the cases (e.g. breast, lung, head and neck) that were typi-
putational power. cally covered over a 3 week period (1 h class per week), were
The applied physics course has therefore been a long-term revised in order to fit within a 2 h time slot. It was felt that
component of the physics curriculum for the radiation oncol- online classes > 2 h in duration would lose the attention of
ogy residency program, and a mandatory component of the trainees learning from home as well, over commit teachers
medical physics residency curriculum. A unique component as they adapted their teaching strategy to this new online
of the course is the intentional inter-professional education, system.
due to the inclusion of both radiation oncology and medical In 2020 and 2021, during the pandemic, the applied
physics learners and faculty. physics course syllabus was shortened to 8 weekly sessions
The applied physics course was given to second year (2 h class per week) and given from April to May. Classes
medical physics residents and PGY3 (post-graduate year 3) were undertaken by video conferencing due to local hospital
and in one year PGY2 and PGY3 radiation oncology resi- restrictions preventing in person learning. In order to keep
dents. In 1991, the course ran from September to February, class size small and encourage trainee discussion, the video
but required expansion to accommodate more complexity in conferencing sessions were repeated such that the class size
treatments. In its recent format (prior to the pandemic), the was maintained to a small number of 5–6 trainees per class
course ran once a week from September to May for a total of (Appendix 2). Trainees uploaded the answers to the case
29 weeks. All sessions were 1 h long and case based except questions prior to each class session. An example of a case
for 5 didactic sessions (Appendix 1). is shown in Appendix 3.
Each session was taught by a pair of faculty members After each teaching session, trainees were given teaching
(one radiation oncologist and one medical physicist). evaluation forms consisting of 6 items (Appendix 4). The

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Journal of Cancer Education (2023) 38:813–820 815

teaching evaluation results were converted to a Likert scale supplemental exam (same format but different cases and
from 1 (strongly disagree) to 5 (strongly agree). Open-ended questions). The supplemental exam was scheduled approxi-
comments regarding teaching quality were also sought with mately 1 month after the first exam. Feedback was given to
each teaching evaluation form. each trainee who did not pass the first exam. All trainees
In 2021, the teaching evaluation sheets were revised with who did not pass the final exam, were successful in passing
an additional 2 items to account for virtual learning (Appen- the supplemental exam.
dix 5). The teaching evaluation results were converted to a Out of a possible 1800 teaching evaluation forms given to
Likert scale from 1 (strongly disagree) to 5 (strongly agree). each trainee to score each teacher and each session taught,
A final examination was given to each trainee at the end there were 366 teaching evaluation forms received. Although
of the course and it consisted of 3 clinical case scenarios, evaluation forms were given to each trainee to score each
with written and oral questions on applied physics concepts teacher for each session, return of completed evaluation
learned throughout the course. The examination included 1 h forms was voluntary. These evaluation forms were received
written preparation for the cases which was then followed by anonymously from each trainee. Open-ended written com-
a 1 h oral set of questions given by 2 faculty examiners (one ments were welcome on each teaching evaluation form.
medical physicist and one radiation oncologist). For the years 2016–2021, the mean and median teaching
During the initial height of the pandemic, in 2020, the evaluation scores (for questions 1–6 Appendix 4) were 4.65
final examination was waived, recognizing our trainees and 5, respectively (range 2–5).
would be experiencing the stress of learning through a new In 2020–2021, due to the covid-19 pandemic, the teach-
virtual format while potentially coping with psychological ing evaluations administered included 2 questions (ques-
effects such as anxiety and fear caused by the pandemic. tions 7 and 8 Appendix 5) regarding the virtual format of the
Some of our radiation oncology residents were also re- course. For these 2 questions relating to the virtual format of
deployed to internal medicine to help with the covid-19 the course, the mean and median responses were 4.14 and 5,
crisis. respectively (range 1–5).
In 2021, after one full year of adapting to working from There were 49 anonymous written comments received.
home and learning through virtual formats, it was felt that These were categorized as positive feedback relating to the
trainees would have adjusted to this new way of teaching session or faculty teacher and feedback regarding areas for
and that they would benefit from having an oral exam albeit improvement. No negative comments were received regard-
through video conferencing. Course coordinators ensured ing teaching quality. There were a total of 41 positive com-
the academic integrity of this final exam by having the train- ments relating to the high quality of teaching or the high
ees complete it online at their host hospitals. quality of the teaching session. These comments included
This study was registered at the local institution as a qual- “Excellent course,” “Excellent teaching,” “Dr. X. is one of
ity improvement project (registration number 72). my favourite teachers in this course. Very knowledgeable
and clear in explanations.” There were 8 comments regard-
ing areas for improvement. Two comments for improvement
Results related to providing slides to the trainees before or after
each teaching session. Four comments related to having the
The number of trainees participating in the applied physics answers to the case-based questions provided to the trainees
course ranged from 7 to 14 per year (2–9 radiation oncology after each session. One trainee commented that time man-
residents per year and 3–6 medical physics residents per agement (too many questions and discussion topics) was an
year). There were 7–12 faculty radiation oncologists who issue for some sessions and that at times the discussions
taught the course per year. Some taught more than one ses- veered off topic. One trainee commented that “virtual is fine
sion. There were 7–9 faculty medical physicists who taught given covid, but a mix of virtual and in person would be
the course per year. Some taught more than one session. better.”
Each session was taught by one medical physicist faculty
together with one radiation oncologist faculty member. Fac-
ulty teachers were chosen based on their evaluations by stu- Discussion
dents for being effective teachers and for their willingness/
availability. This study is the first to report a structured applied phys-
The end of course exam was completed by all train- ics course in an accredited radiation oncology and medical
ees. One faculty medical physicist and one faculty radia- physics training program. This applied physics course is a
tion oncologist administered the end of course examina- component of a larger physics curriculum given to our radia-
tion. Ninety-four percent of trainees passed the final exam. tion oncology and medical physics residents. The overall
Trainees who did not pass the final exam were given a scope for physics education in radiation oncology resident

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816 Journal of Cancer Education (2023) 38:813–820

training has, for example, been detailed in The American administered included 2 questions (questions 7 and 8 Appen-
Society for Radiation Oncology’s (ASTRO’s) 2015 core dix 5) regarding the virtual format of the course. For these
physics curriculum [7]. The ASTRO 2015 physics curricu- 2 questions relating to the virtual format of the course, the
lum for residents outline suggested lecture hours on top- mean and median responses were 4.14 and 5, respectively
ics, learning objectives and textbook references. Site-based (range 1–5). One respondent preferred an in class setting or
modules are also available listing common radiation treat- a mix of in class and virtual sessions.
ment techniques based on body site. The intent of ASTRO’s The transition to virtual learning did help address pro-
physics-based learning modules is to provide an observa- grammatic feedback for the physics residency program as it
tional experience that supplements didactic education and has eliminated the need to travel which was quite extensive
clinical rotation experience. Our program is unique in that for some residents, with a 1 h course necessitating a full
we have supplemented physics learning with a formal struc- morning commitment of travel. Transitioning to virtual for-
tured case–based applied physics course. mat had been discussed previously but course coordinators
Furthermore, inter-professional education is recognized and lecturers were hesitant to switch the format before it was
as an important component to improving healthcare deliv- necessitated by the pandemic.
ery and patient outcomes [14]. The format of this applied Although in person, class-based applied physics teaching
physics course demonstrates inter-professional education may be preferred by some residents, our experience suggests
between medical physicists and radiation oncologists. This that a case-based applied physics course could be delivered
structured opportunity provides learners an understanding of virtually. This could be useful, especially for small pro-
each other’s professional roles. Not only are applied physics grams without a structured applied physics curriculum. For
concepts and principles learned, learners also practice and example, established applied physics courses based on clini-
establish effective communication skills. cal cases could be offered to smaller programs and offered
Each session was guided by teaching faculty (one medi- virtually.
cal physicist and one radiation oncologist). This format was
well-received by the trainees. Having both a medical physi-
cist and radiation oncologist, respectively, enabled insight- Future Plans
ful medical physics and clinical radiotherapy perspectives.
The cases developed for each session were chosen based on Our national radiation oncology training program has initi-
common clinical scenarios and based on the ability of the ated a “Competence by Design” medical education frame-
case to highlight key physics concepts. In order to keep up to work. This involves a list of learning objectives called
date with respect to medical physics and radiation oncology Entrustable Professional Activities (EPAs) and milestones.
practice [15, 16], the syllabus of cases is reviewed yearly As part of our national radiation oncology curriculum
by a teaching faculty and is revised according to changes in re-design, the applied physics course will be given to PGY2
evolving technology available and evolving clinical practice. radiation oncology residents and continue to be given to sec-
The applied physics examination results reveal that the ond year physics residents. Applied physics teaching content
initial pass rate was high at 94% and subsequently was 100% will be reviewed and edited yearly.
for those who took a supplemental exam (after not passing Specifically with respect to our national radiation oncol-
the initial exam). Because this applied physics exam was ogy competencies, residents are expected to develop seven
a smaller component of the overall physics and radiation themed roles: Medical expert (the integrating role), com-
oncology curriculum, we did not examine the overall pass municator, collaborator, leader, health advocate, scholar,
rate for these trainees on the national specialty board certi- and professional. The applied physics course covers many
fication exam. The main goal for this course was to enable of the radiation oncology competencies defined under these
residents to achieve competency with respect to applied themed roles [17].
physics principles [16]. It was not within the scope of this Our training program will continue to track resident
course to evaluate overall clinical competency. performance in the physics curriculum as well as in other
The success of this course depends on a dedicated fac- formal examinations such as our radiation planning exams,
ulty who demonstrates excellent teaching skills. The results which incorporates core physics principles. Radiation oncol-
from the teaching evaluation scores indicate that the trainees ogy residents will continue to have weekly academic half-
highly valued the teaching sessions and teachers. day teaching where physics-related concepts are incorpo-
During 2020 and 2021, this applied physics course tran- rated into didactic teaching and case-based scenarios. These
sitioned to a virtual teleconference format. Our experience structured learning opportunities help ensure that applied
indicated that the nature of this course (case-based discus- physics fundamentals are integrated competently into daily
sions) was adaptable to a virtual format. In 2020–2021, practice. Our applied physics curriculum is expected to con-
due to the covid-19 pandemic, the teaching evaluations tinue to evolve based on national accreditation standards,

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Journal of Cancer Education (2023) 38:813–820 817

with evolving technological changes and with feedback from Week Group Case
teachers and learners.
4 2 3 Lung
1 4 Skin
5 1 5 Gynecology
Appendix 1. 2016–2019 Applied physics
2 6 Colorectal
teaching sessions
6 2 5 Gynecology
1 6 Colorectal
Sessions: 7 1 7 Head and Neck
2 8 Radionuclides and Radioprotec-
1. Didactic review of radiation physics tion
2. Case 1 Breast 8 2 7 Head and Neck
3. Case 2 Breast 1 8 Radionuclides and Radioprotec-
4. Case 3 Breast tion
5. Case 4 Gynecology
6. Case 5 Lung introduction
7. Case 6 Lung
8. Case 7 Lung Appendix 3. Case example:
9. Didactic radionuclide therapy: clinical aspects
10. Case 8 Colorectal CASE 1 BREAST
11. Case 9 Lower GI-pancreas
12. Case 10 Prostate Consider a 42 year old female with a T2N0 ca breast for
13. Case 11 Head and neck adjuvant radiation following a lumpectomy.
14. Case 12 Head and neck Questions:
15. Case 13 Head and neck
16. Case 14 Skin 1. Using illustrations, describe a technique (e.g. beam
17. Case 15 Lymphoma arrangement, patient positioning, immobilization) that
18. Didactic brachytherapy physics will adequately treat all breast tissue while minimizing
19. Case 16 Brachytherapy (tongue) dose to the critical structures. What dose would you pre-
20. Case 17 Prostate seed implant scribe?
21. Case 18 Prostate HDR 2. What factors contribute to a non-uniform dose distribu-
22. Case 19 Gynecology brachytherapy tion in the breast?
23. Case 20 Didactic radiation protection 3. Describe how a physical wedge, virtual wedges and
24. Case 21 Brain stereotactic MLC-based segments (control points) can be used to
25. Case 22 Total body irradiation create a “wedged distribution”.
26. Case 23 Craniospinal irradiation 4. Using your above illustrations, draw and describe an
27. Didactic quality assurance part 1 acceptable isodose distribution.
28. Case 24 Quality assurance 5. What happens to the dose distribution as the separation
29. Didactic Plan review and evaluation increases? Consider choice of beam energy as a function
of separation.

CASE 2 BREAST
Appendix 2. Pandemic 2020–2021 applied
physics teaching sessions A 50 year old female with T2N3 ca breast requires radiation
to the entire breast following a lumpectomy.
Questions:
Week Group Case
1. Identify the GTV, CTV and PTV. What are the critical
1 1 1 Breast
structures and dose constraints? What dose would you
2 2 Prostate
prescribe?
2 2 1 Breast
2. Using illustrations, describe a technique which will treat
1 2. Prostate
the breast and nodal regions using photons. Consider
3 1 3 Lung
beam arrangement, patient positioning, immobilization,
2 4 Skin

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818 Journal of Cancer Education (2023) 38:813–820

beam junctions and dose uniformity throughout the vol- Learning Objectives:
ume. Clinical:
3. What can you expect the dose across the junction to be?
If gross disease is present at the level of the junction, • Treatment volumes: GTV, CTV, PTV
how could you increase dose coverage? • Field arrangement: tangential-opposed and 4-field
4. How would you modify the technique if the internal • Patient positioning and immobilization
mammary chain (IMC) nodes need to be included in • Photon beam junctions
the treatment volume? What is the impact of this modi-
fied technique on the critical structures? Applied Physics:
5. Following her four field irradiation, the patient, whose
biopsy showed positive lumpectomy margins, requires • Influence of missing tissue (or lung), increasing separa-
a boost to the lumpectomy site. How would you identify tion and increasing energy on parallel-opposed field dose
the CTV for the boost site? What margins would you use distributions
for the PTV boost? • Methods of missing tissue compensation: wedges
6. Describe two photon beam arrangements that one might • Methods of creating ‘wedged’ distributions: Physical
use to treat the boost volume. wedge, Virtual wedge, MLC-based segments (control
points)

Appendix 4. Teaching evaluation surveys (2016–2019)

1. Communicated ideas
Strongly disagree Disagree Equivocal Agree Strongly agree

2. Demonstrated breadth of knowledge and ability to analyze information

Strongly disagree Disagree Equivocal Agree Strongly agree

3. Questioned and challenged students

Strongly disagree Disagree Equivocal Agree Strongly agree

4. The complexity of the material covered was appropriate to my level of training

Strongly disagree Disagree Equivocal Agree Strongly
agree

5. The teacher explained ideas and concepts clearly

Strongly disagree Disagree Equivocal Agree Strongly
agree

6. The session increased my knowledge

Strongly disagree Disagree Equivocal Agree Strongly
agree

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Journal of Cancer Education (2023) 38:813–820 819

Appendix 5. Teaching evaluations during the pandemic

1. Communicated ideas
Strongly disagree Disagree Equivocal Agree Strongly agree

2. Demonstrated breadth of knowledge and ability to analyze information

Strongly disagree Disagree Equivocal Agree Strongly agree

3. Questioned and challenged students

Strongly disagree Disagree Equivocal Agree Strongly agree

4. The complexity of the material covered was appropriate to my level of training

Strongly disagree Disagree Equivocal Agree Strongly
agree

5. The teacher explained ideas and concepts clearly

Strongly disagree Disagree Equivocal Agree Strongly
agree

6. The session increased my knowledge

Strongly disagree Disagree Equivocal Agree Strongly
agree

7. The virtual technology used for this applied physics session is equivalent to learning
during an in-person classroom session
Strongly disagree Disagree Equivocal Agree Strongly
agree
8. This applied physics session should continue to be given via the virtual technology
used
Strongly disagree Disagree Equivocal Agree Strongly
agree

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820 Journal of Cancer Education (2023) 38:813–820

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tation: the American College of Radiation Oncology, Practice
Accreditation Program, guidelines and standards. Crit Rev Oncol
Conflict of interest The authors declare no competing interests.
Hematol 55(2):92–102
11. Li R, Shinde A, Novak J et al (2020) Temporal trends of resident
experience in external beam radiation therapy cases: analysis of
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