Part I: Defining the Structured Training Program
Contract Agreement with an External Qualified Radiation Oncology Trainer
As many professionals left the country from the 1990s onward, it was impossible to establish an advanced (board-level) program in this field without the availability of a single board-certified radiation oncology trainer locally (Mula-Hussain and Al-Ghazi 2020). Radiation oncology is a complex clinical field and requires well-trained personnel. Investment in personnel should precede that in equipment to achieve a satisfactory outcome. Based on this, the first step was to choose a board-certified person from abroad and qualified to lead the effort of establishing such a program locally. To achieve this goal, ZCC in Sulaimani started to contact external trainers during the 2010s. Eventually, the officials from the Regional Ministry of Health signed a four-year contract with an external trainer (the author of this chapter).
The local leaders of ZCC invited this external trainer to visit the center in 2011 to address its suitability for the postgraduate accredited training program. The visitor examined the infrastructure and the available human and equipment resources. He wrote a visit report with recommendations to update the available equipment resources and a roadmap for moving forward. This visit was also coupled with meeting the academic leadership team at the KBMS to meet their organizational requirements in postgraduate medical education and recognition. After about 18 months from the visit report and following the recommendations, the external trainer returned to ZCC to start the in-house training process in the second quarter of 2013.
With the in-house external trainer’s availability, ZCC got the accreditation of the KBMS to be a certified training center in radiation oncology for a four-year residency program. Another accreditation followed this recognition by the College of Medicine—the University of Sulaimani for an alternative three-year Master of Science (MSc) program in radiation oncology (for those who already have a minimum of one-year training in radiation oncology).
Definition, Mission, and Vision
The training pathway is settled to let the trainee acquire knowledge in oncologic science and gain clinical experience in radiation oncology. The mission was defined as “serving patients, the public, and the medical profession by certifying that ZCC diplomates have acquired, demonstrated, and maintained the requisite standard of knowledge, skill, understanding, and performance essential to the safe and competent practice of radiation oncology” (Datta et al. 2014). The vision is that by 2020, ZCC will have advanced safety and quality in healthcare by setting definitive professional standards for radiation oncology (Mula-Hussain 2013), which it has achieved.
Training and Study Syllabus
The syllabus was devised using well-structured resources in clinical radiation oncology programs, like the syllabi from the Royal College of Radiologists in the UK, the Royal Australian and New Zealand College of Radiologists, the CanMEDS framework of the Royal College of Physicians and Surgeons of Canada, the American Board of Radiology, and the International Atomic Energy Agency (IAEA) syllabus that was endorsed by the American Society for Therapeutic Radiology and Oncology (ASTRO) and the European Society for Therapeutic Radiology and Oncology (ESTRO). There were 10 modules, with 100 credits over 4 years in the KBMS board program and 75 credits over 3 years in the university MSc program. The residents have to achieve the seven competency requirements (medical experts, communicators, collaborators, leaders, advocates, scholars, and professionals in radiation oncology, as defined by CanMEDS). The academic credits are summarized in Table 1 (Mula-Hussain 2013).
For the length of the structured training, we opted to make it full-time 4 years in radiation oncology, following the Royal College of Physicians and Surgeons of Canada and the American Board of Radiology. Due to administrative logistics and the need to increase the acceptance but keeping the quality, we designed an alternative pathway of specialty certification through the university and of a full-time 3-year course of study leading to the MSc degree for those who already have 1 year of uncategorized training in radiation oncology. For the latter, we followed the well-established syllabi adopted by the Royal College of Radiologists in the UK and the IAEA syllabus (International Atomic Energy Agency 2009).
Admission and Academic Requirements
The main admission requirements include graduation from a recognized medical school by the ministry of higher education, hold a practice license by the medical association, and completion of a rotatory general residency of a minimum of 12 months. Applicants must pass the entry examination in oncology foundations, be good English users, and successfully pass the personal interview (Mula-Hussain 2013). Each trainee must publish a paper in a peer-reviewed journal and/or complete a research thesis in the final year of training. According to the board and university regulations, every specialist needs to show scientific merit and critical appraisal before getting a certification degree in that particular field.
Clinical Training (Major and Minor Rotations)
Under supervision, residents rotate in four groups, two residents each, sequentially. Each major rotation has a duration of 3 months in radiation oncology and is repeated three to four times during the studies with increasing independence granted to residents as their skills develop. During each rotation, the resident passes through new patients’ clinics, on-treatment clinics, posttreatment follow-up clinics, simulation techniques, volumes’ contouring, and plan evaluation sessions. Minor rotations were arranged, too, each of 2–4 weeks duration, in diagnostic radiology, tumor pathology, medical oncology, surgical oncology, palliative care, and cancer research (Mula-Hussain 2013).
Evaluation, Promotion, and Examination
A regular evaluation, that is, a written examination and oral assessment, was arranged at the end of each clinical rotation and each didactic course. Annual evaluation (written examination and practical assessment) was organized at the end of each training year. Feedback from all the peers and co-workers was considered. However, the infrastructure so far was not permissive to a 360° review. On campus (at ZCC) and a yearly report were sent to the KBMS and the university about promoting the trainee to the following year. Part one examination was conducted at the KBMS and the university after successful completion of the first year. The final examination took place at the KBMS and university upon successful completion of the last year. A significant guideline for assessment is to see if the candidate demonstrates the competency to practice safely and independently. This examination consisted of two written exams (over 2 days) and an oral and practical OSCE examination (set by external, volunteering examiners).
Successful completion of the curriculum results in the award of the title of “Fellow” (post-nominal “FKBMS”) by KBMS or the MSc in radiation oncology by the University of Sulaimani.
Part II: Adjunctive Collaborative Opportunities
Internal Academic Assistance
Radiation oncology practice is closely related to many basic and clinical sciences. Based on the syllabus, contact with local academics at the University of Sulaimani was arranged to cover the required subjects. All of them enthusiastically helped in covering the syllabus.
International Individual Assistance
Individual contacts with colleagues in different disciplines and countries were made to arrange short professional visits to ZCC. This proved to be successful. Many colleagues from various disciplines and countries (Jordan, Saudi Arabia, the UK, the USA, Canada, and Italy) visited ZCC and spent days to weeks working voluntarily with the local mentors and residents. These visitors shared their expertise as lecturers and trainers and as external examiners in the final year of OSCE examination for the first cohort in May 2017.
Global Institutional Networking
Considerable efforts were made to establish external outreach with international centers and organizations. Memoranda of understanding were arranged with centers in Turkey, India, the USA, and Canada. ZCC obtained membership of the most extensive global umbrella for cancer control, the Union for International Cancer Control (UICC), making it the first in Iraq.
ACR (American College of Radiology) In-Training Examination
In an endeavor to standardize our training program in line with international programs in developed countries, the American College of Radiology allowed our residents to enroll in its annual in-training examination in March 2017 after arranging the required examination fees. Seven ZCC residents sat the examination on the same day as their peers in the USA. They did well in general; even one of them passed his peers’ mean in the USA. This provides benchmarking for both the residents and their program.
This orientation and benchmarking experience was, however, not repeated due to financial hardship of the ZCC resulting in a lack of providing the necessary infrastructure for its proper conduct. It would be desirable to provide this examination for the current and coming residents in order to secure an objective measure for the teaching success.
Scientific Meetings and Courses
To further improve evidence-based, multidisciplinary approaches to cancer care, ZCC was successful in arranging the following four international activities:
Multi-Disciplinary Oncology Course series in Iraq (February 2015) covered general cancer care, a five-day course attended by 206 attendees.
Best of ASTRO Iraq meeting (December 2015), officially licensed by ASTRO, covered best abstracts from the 2015 annual ASTRO meeting, with 197 attendees.
Multi-Disciplinary Oncology Course series in Iraq, second course, covered gynecologic oncology in September 2016, over 2 days, attended by 227 attendees.
Best of ASTRO Iraq meeting (May 2017), officially licensed by ASTRO, covered best abstracts from the 2016 annual ASTRO meeting, attended by 152 attendees.
In addition to attendance and benefiting from these events’ scientific opportunities, the residents presented their work and assumed organizational and leadership roles. The invited external speakers shared their expertise in teaching the residents through dedicated “meet the professor” sessions. They also joined ZCC examination days that were arranged in the periods of the meetings.
Online Education and Telemedicine Tools
Some of the program residents were able to further improve their educational knowledge through accessing ESTRO School FALCON courses (Fellowship in Anatomic DeLineation and CONtouring). One of the residents, who participated in this international course in 2017, came first among all the international participants and was acknowledged by IAEA during the International Conference in Advanced Radiation Oncology in Vienna, June 2017.
Quality and Safety Culture
ZCC fosters a culture of quality and safety. All residents, physicists, therapists, and other staff are obliged to report any incidents or accidents during daily work. An emphasis on the double- and triple-check is the norm to improve patient care safety and quality. This includes but is not limited to contours and plan check, treatment delivery, and the entire patient care process.
External Training Opportunities
Some of the residents participated in a palliative care course organized locally by an international expert. Other residents attended international clinical attachments for some days and weeks to months at advanced centers in Turkey, the UK, and the USA.
Research Promotion and Collaboration
Simultaneously and in parallel with the education and clinical training program, research activities were supported. During the period 2013–2018, ZCC residents and staff accomplished 2 books, 7 theses, 10 peer-reviewed manuscripts, 19 oral presentations (5 were international), and 17 poster international presentations covering miscellaneous topics (Mula-Hussain et al. 2019b). ZCC hosted an international student from the University of Toronto for 4 weeks in 2017 to let her voluntarily help in a supervised medical and laboratory experience and assist in the residents’ research activities from the English language editing perspective.
Local Funding and Supporting Opportunities
Civil society, nongovernmental organizations, the private sector, and philanthropic individuals in Sulaimani and across Iraq were approached to help the training center and its educational programs and scientific activities. This proved to be helpful to ZCC in furthering its clinical and educational mission. These opportunities helped in covering the costs of the four scientific events that ZCC arranged, the membership cost at UICC, partial support of the external visits that the residents did abroad, costs of the travel and accommodation expenses of the external short-stay trainers and lecturers, updating some of the tools and equipment at ZCC, etc.