Old humanities and new science in radiation oncology

“Every man has a philosophy of life in thought, in word or in deed, worked out in himself unconsciously. In possession of the very best, he may not know of its existence” A way of life-an address to Yale students 1913—Sir William Osler It has been more than 129 years since X-ray was discovered by Wilhelm Conrad Roentgen (a German mechanical engineer and physicist) on November 8, 1895. Subsequently, radioactivity was discovered by Antoine Henri Bacquerel (a French engineer and physicist) in 1896 and radium was discovered by Marie Curie (a Polish and naturalized French physicist and chemist) and her husband Pierre Curie (a French physicist) on December 21, 1898. Almost immediately after discovery, ionizing radiation (either X-ray or radiation due to spontaneous radioactivity of radioisotopes) was applied to various medical conditions on both sides of the Atlantic, leading to the birth of a new medical specialty of radiology (including diagnostics and therapy). Since then the scientific development and growth of therapeutic radiology or radiation oncology have been both successful and useful to society. In the past 100 years, the technological advancement of radiation oncology has been immense, and the discipline has evolved much beyond conventional treatment. Worldwide, it has been able to achieve a significant reduction in morbidity and mortality due to cancer. Almost 60% of cancer patients require radiotherapy as part of their treatment at some point in time of treatment of cancer. From a public health point of view in low and middle-income countries, it is a both cost-effective and fruitful treatment modality for cancer for cure and palliation. Therefore, it is important to develop a competency-based in-service training system in radiation oncology, which can fulfill the challenges of learning requirements of modern times. If we consider the latter half of the nineteenth century and early part of the twentieth century as the era of evolution of medical specialties (including radiology, bacteriology, genetics, and endocrinology) it was also the era of consolidation of clinical medicine. During this period, The Johns Hopkins Hospital and Medical School was established under the medical leadership of “the Big Four”: Sir William Osler in Medicine, William Stewart Halsted in Surgery, William Henry Welch in pathology, and Howard Atwood Kelly in obstetrics and gynecology. Sir William Osler, who later became the Regius Professor of Medicine in Oxford, is regarded as the father of Western clinical medicine and introduced bedside teaching and clinical clerkship for medical students. Demonstration and training of bedside clinical skills to medical students dominated medical education for many years since the “Oslerian philosophy” was introduced. It had a profound impact on medical education. Studies show that it represented almost 70% of medical training in the 1960s. It is well established that thorough and correct history and physical examination can provide almost accurate diagnosis in 73% of cases, which can be over 90% in certain cases as medical diagnosis involves a significant amount of pattern recognition.[1] Bedside teaching also helps medical students to communicate effectively and ethically with patients in the real world. Though the experiment-based evidence is limited, experience-based expert opinion always underlines the importance of bedside teaching. This has given rise to the concept of in-service training especially for postgraduates and the concept of residency training. Radiation Oncology, being a clinical discipline, is no exception to it. Thorough history taking, clinical examination, and effective communication with patients have always been a priority of specialty training programs. It was widely accepted that the most important aim of post post-graduate training program in radiotherapy was to produce radiation oncologists who would practice the therapeutic use of ionizing radiation safely, and communicate with the patient and family about the disease effectively and accurately to the extent possible. William Osler said, “To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” Since 1900, this has been the philosophy of the medical education system and has been applied to almost all clinical branches. He also remarked “Life is a habit, a succession of action that becomes more or less automatic.”[2] Medical students through supervised training under medical teachers also used to develop an interest in the story of life, and biographical subjects. This inculcated a strong conviction of its value in education, which was passed on to the next generation through student–teacher relationships or peer interactions.[3] For a long time the profession was dominated by general physicians but the old values were seriously questioned in the latter half of the twentieth century with the advent of specialization and super specialization. Gosta Forsell introduced the Stockholm system of brachytherapy in 1913, which was followed by the French system and Manchester system by Todd and Meredith. Eventually, the preloaded radium source was replaced with manual after loading cesium source and finally to remote after loading system. Similarly for external beam radiotherapy, initially treatment was given with a modified cathode ray tube, X-ray tube, and Finsen lamp. Orthovoltage X-ray or superficial X-ray machines had many limitations, particularly in treating deep-situated tumors. The invention of nuclear reactors during World War II culminated in the discovery of artificial radioisotopes. This led to the use of medical isotopes in cancer treatment beyond naturally occurring radium isotopes. The first patient was treated with a Telecobalt machine on October 27, 1951, at War Memorial Children’s Hospital, London, ON, Canada. The use of Linear accelerators has been widespread since the 1970s. There was a sea-change in medical science during the twentieth century, especially after the 1950s, due to the rapid advancement of technology. Probably, radiation oncology is one of the disciplines, which made great advancement taking advantage of the technological innovation. In 1946 Edward Purcell (an American physicist) and Felix Bloch (a Swiss American physicist) discovered nuclear magnetic resonance. This discovery and many other subsequent discoveries in related technology formed the basis for magnetic resonance imaging technology.[4,5] GodfrayHounsfield (a British electrical engineer) and Allan McLeod Cormack (a South African-American physicist) developed computer-assisted tomography and it was introduced in medical practice on October 1, 1971.[6] The first paper on intensity-modulated radiation therapy (IMRT) was published in 1982 and in 1989, Webb conceptualized IMRT, as an optimization problem.[7,8] Introduction of image-guided brachytherapy and intensity-modulated radiotherapy brought a paradigm shift in the practice of radiation oncology. Gartner hype cycles provide a graphic representation of the maturity and adoption of technologies and applications and help to understand how rapidly technology is harnessed to use in practice. Application of this theory in radiation oncology reveals the time of adoption of the technology in clinical practice is progressively reduced over time. For example, the Monte Carlo method came into routine practice almost 20 years after discovery, but artificial intelligence took less than 7 years for wide application in radiation oncology. Technological advancements like imaging, hybrid imaging, theranostic imaging, and biological innovations in the fields of nanotechnology, stem cells, and tissue engineering have changed the prospect of radiation oncology in cancer treatment. Knowledge-based planning, robust planning, and patient-specific quality assurance have made the delivery of radiation much more precise and accurate. Modern radiation has evolved beyond photons and electrons to encompass protons, heavy ions, hadrons, and newer forms of radiation with different biological effects. It needs to be examined whether this spectacular technological advancement has made a great impact on public health, especially in low and medium-income countries. The establishment of a radiation facility is still very costly. The development of indigenous cost-effective solutions to make this treatment more accessible, affordable, and effective is the need of the hour. Old humanities need to be blended with new developments in science and technology in a nationally relevant, India-specific, competency, and skill-based curriculum. Brachytherapy is one of the skills, which need to be more widely accessible as it often provides cost-effective solutions. There is a need to produce academic leadership in radiation oncology through the development of super specialty courses like Doctorate of Medicine (DM) courses or physician-scientist training programs (MD-PhD), which will help to strengthen the clinical service, education, and research in India. A changing hospital and learning environment together with a greater technological reliance and other practical obstacles are frequently argued in the literature as impediments to bedside teaching. However, there are no real arguments directed at the rationale of bedside teaching as a possible successful educational option.[1] As civilization progresses, society adapts itself gradually to new challenges. The same is true for science, technology, and medicine. Bronowski[9] rightly remarked that man invented a thing like a plow or a boomerang or a wheel or a hut out of necessity. Technology, primitive, and modern is based on the same basic principle. When we breed new strains of corn, we follow the same aim as the first farmers to produce food.[9] Therefore, old humanities and new science are not essentially contradictory. Medical education and training need to adapt to the new challenges of the twenty-first century. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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