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Background Dedifferentiated chondrosarcoma is a chondrosarcoma subtype associated with high rates of recurrence and a poor prognosis. Others have proposed treatment of dedifferentiated chondrosarcoma using osteosarcoma protocols, including perioperative chemotherapy. However, the rarity of this condition poses difficulties in undertaking single- institution studies of sufficient sample size. Question/purpose Is perioperative chemotherapy associated with improved overall survival in patients with dedifferentiated chondrosarcoma? Methods We queried the Surveillance, Epidemiology, and End Results (SEER) 1973 to 2016 database for patients with a diagnosis of dedifferentiated chondrosarcoma (n = 308). As dedifferentiated chondrosarcoma was only classified as a distinct entity in SEER starting in 2000, only patients treated in 2000 and later were included. We excluded from our analyses those patients with distant disease at diagnosis, a primary site of disease other than bone or joints, and those who did not receive cancer-directed surgery. These criteria yielded 185 dedifferentiated chondrosarcoma patients for inclusion. We used Kaplan-Meier analyses and Cox proportional hazards models to assess the association of clinical, demographic, and treatment characteristics on overall survival (OS). Results After controlling for confounding variables, including age, sex, tumor size, stage, grade, location, and radiation treatment status, and after adjusting for missing data, no overall survival benefit was associated with receipt of chemotherapy in patients with dedifferentiated chondrosarcoma (hazard ratio 0.75 [95% confidence interval 0.49 to 1.12]; p = 0.16). Conclusion Chemotherapy treatment of dedifferentiated chondrosarcoma was not associated with improved OS. These results must be viewed cautiously, given the limited granularity of information on chemotherapy treatment, the concerns regarding chemotherapy misclassification in SEER data, and the small sample of patients with dedifferentiated chondrosarcoma, all of which limit the power to detect a difference. Our findings are nevertheless consistent with those of prior reports in which no benefit of chemotherapy could be detected. Lack of clear benefit from perioperative chemotherapy in dedifferentiated chondrosarcoma argues that it should be used only after careful consideration, and ideally in the context of a clinical trial. Level of evidence Level III, therapeutic study.

Background Physicians and physicists are expected to contribute to patient safety and quality improvement (QI) in Radiation Oncology (RO), but prior studies suggest that training for this may be inadequate. RO and medical physics (MP) program directors (PDs) were surveyed to better understand the current patient safety/QI training in their residency programs. Methods PDs were surveyed via email in January 2017. Survey questions inquired about current training, curriculum elements, and barriers to development and/or improvement of safety and QI training. Results Eighty-nine RO PDs and 84 MP PDs were surveyed, and 21 RO PDs (28%) and 31 MP PDs (37%) responded. Both RO and MP PDs had favorable opinions of current safety and QI training, and used a range of resources for program development, especially safety and QI publications. Various curriculum elements were reported. Curriculum elements used by RO and MP PDs were similar, except RO were more likely than MP PDs to implement morbidity and mortality (M&M) conference (72% vs. 45%, p

Purpose The purpose of this study was to assess the state of palliative and supportive care (PSC) and palliative radiation therapy (RT) educational curricula in radiation oncology residency programs in the United States. Methods and materials We surveyed 87 program directors of radiation oncology residency programs in the United States between September 2015 and November 2015. An electronic survey on PSC and palliative RT education during residency was sent to all program directors. The survey consisted of questions on (1) perceived relevance of PSC and palliative RT to radiation oncology training, (2) formal didactic sessions on domains of PSC and palliative RT, (3) effective teaching formats for PSC and palliative RT education, and (4) perceived barriers for integrating PSC and palliative RT into the residency curriculum. Results A total of 57 responses (63%) was received. Most program directors agreed or strongly agreed that PSC (93%) and palliative radiation therapy (99%) are important competencies for radiation oncology residents and fellows; however, only 67% of residency programs had formal educational activities in principles and practice of PSC. Most programs had 1 or more hours of formal didactics on management of pain (67%), management of neuropathic pain (65%), and management of nausea and vomiting (63%); however, only 35%, 33%, and 30% had dedicated lectures on initial management of fatigue, assessing role of spirituality, and discussing advance care directives, respectively. Last, 85% of programs reported having a formal curriculum on palliative RT. Programs were most likely to have education on palliative radiation to brain, bone, and spine, but less likely on visceral, or skin, metastasis. Conclusions Residency program directors believe that PSC and palliative RT are important competencies for their trainees and support increasing education in these 2 educational domains. Many residency programs have structured curricula on PSC and palliative radiation education, but room for improvement exists in management of fatigue, assessing role of spirituality, and discussion regarding advance care planning.

Purpose Tools for assessing the severity and risk of near-miss events in radiation oncology are few and needed. Recent work has described guidelines for the use of a 5-tier near-miss risk index (NMRI) for the classification of near-miss events. The purpose of this study was to assess the reliability of the NMRI among users in a radiation oncology department. Methods and materials Reliability of the NMRI was assessed using an online survey distributed to members of a radiation oncology department. The survey contained 70 events extracted from the department's incident learning system (ILS). Survey participants rated each event using the NMRI guidelines, reported their attendance to weekly ILS meetings (used as a surrogate for familiarity with the ILS), and indicated their familiarity with the radiation oncology workflow. Interrater reliability was determined using Krippendorff's alpha. Use of the NMRI to rate actual events during 5 weekly ILS meetings was also assessed and interrater reliability determined. Results Twenty-eight survey respondents represented a wide variety of care providers. Krippendorff's alpha was calculated for the whole respondent cohort to be 0.376, indicating fair agreement among raters. Respondents who had the most participation at ILS meetings (n = 4) had moderate agreement with an alpha of 0.501. Interestingly, there were significant differences in reliability and median NMRI scores between professions. NMRI use during weekly NMRI meetings (80 events rated), participants showed moderate reliability (alpha = 0.607). Conclusions Using the NMRI guidelines, raters from a wide variety of professions were able to assess the severity of near-miss incidents with fair agreement. Those experienced with the ILS showed better agreement, and higher agreement was seen during multidisciplinary ILS meetings. These data support the use the indices such as the NMRI for near-miss risk assessment in patient safety and prioritization of process improvements in radiation oncology.

Purpose Create a cost-effectiveness model comparing preoperative intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3DCRT) for extremity soft tissue sarcomas. Methods and Materials Input parameters included 5-year local recurrence rates, rates of acute wound adverse events, and chronic toxicities (edema, fracture, joint stiffness, and fibrosis). Health-state utilities were used to calculate quality-adjusted life years (QALYs). Overall treatment costs per QALY or incremental cost-effectiveness ratio (ICER) were calculated. Roll-back analysis was performed using average costs and utilities to determine the baseline preferred radiation technique. One-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed for input parameters with the largest impact on the ICER. Results Overall treatment costs were $17,515.58 for 3DCRT compared with $22,920.51 for IMRT. The effectiveness was higher for IMRT (3.68 QALYs) than for 3DCRT (3.35 QALYs). The baseline ICER for IMRT was $16,842.75/QALY, making it the preferable treatment. The ICER was most sensitive to the probability of local recurrence, upfront radiation costs, local recurrence costs, certain utilities (no toxicity/no recurrence, grade 1 toxicity/no local recurrence, grade 4 toxicity/no local recurrence), and life expectancy. Dominance patterns emerged when the cost of 3DCRT exceeded $15,532.05 (IMRT dominates) or the life expectancy was under 1.68 years (3DCRT dominates). Furthermore, preference patterns changed based on the rate of local recurrence (threshold: 13%). The PSA results demonstrated that IMRT was the preferred cost-effective technique for 64% of trials compared with 36% for 3DCRT. Conclusions Based on our model, IMRT is the preferred technique by lowering rates of local recurrence, severe toxicities, and improving QALYs. From a third-party payer perspective, IMRT should be a supported approach for extremity soft tissue sarcomas.

Rigorous use of departmental incident learning is integral to improving patient safety and quality of care. The goal of this study was to quantify the impact of a high-volume, departmental incident learning system on patient safety culture.A prospective, voluntary, electronic incident learning system was implemented in February 2012 with the intent of tracking near-miss/no-harm incidents. All incident reports were reviewed weekly by a multiprofessional team with regular department-wide feedback. Patient safety culture was measured at baseline with validated patient safety culture survey questions. A repeat survey was conducted after 1 and 2 years of departmental incident learning. Proportional changes were compared by χ(2) or Fisher exact test, where appropriate.Between 2012 and 2014, a total of 1897 error/near-miss incidents were reported, representing an average of 1 near-miss report per patient treated. Reports were filed by a cross section of staff, with the majority of incidents reported by therapists, dosimetrists, and physicists. Survey response rates at baseline and 1 and 2 years were 78%, 80%, and 80%, respectively. Statistically significant and sustained improvements were noted in several safety metrics, including belief that the department was openly discussing ways to improve safety, the sense that reports were being used for safety improvement, and the sense that changes were being evaluated for effectiveness. None of the surveyed dimensions of patient safety culture worsened. Fewer punitive concerns were noted, with statistically significant decreases in the worry of embarrassment in front of colleagues and fear of getting colleagues in trouble.A comprehensive incident learning system can identify many areas for improvement and is associated with significant and sustained improvements in patient safety culture. These data provide valuable guidance as incident learning systems become more widely used in radiation oncology.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, practice facilitation, which is a common strategy in primary care to help practices develop capacity and infrastructure to support their ability to improve patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe practice facilitation, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report practice facilitation efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of practice facilitation.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, interprofessional education (IPE), which is a common intervention in health professions education. IPE is an opportunity for individuals of multiple professions to interact to learn together, to break down professional silos, and to achieve interprofessional learning outcomes in the service of high-value patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe IPE, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and to build on this guideline as they plan, implement, evaluate, and report IPE efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of IPE.

Education in patient safety and quality of care is a requirement for radiation oncology residency programs according to accrediting agencies. However, recent surveys indicate that most programs lack a formal program to support this learning. The aim of this report was to address this gap and share experiences with a structured educational program on quality and safety designed specifically for medical physics therapy residencies. Five key topic areas were identified, drawn from published recommendations on safety and quality. A didactic component was developed, which includes an extensive reading list supported by a series of lectures. This was coupled with practice‐based learning which includes one project, for example, failure modes and effect analysis exercise, and also continued participation in the departmental incident learning system including a root‐cause analysis exercise. Performance was evaluated through quizzes, presentations, and reports. Over the period of 2014–2016, five medical physics residents successfully completed the program. Evaluations indicated that the residents had a positive experience. In addition to educating physics residents this program may be adapted for medical physics graduate programs or certificate programs, radiation oncology residencies, or as a self‐directed educational project for practicing physicists. Future directions might include a system that coordinates between medical training centers such as a resident exchange program.

Purpose Incident learning systems (ILSs) are a popular strategy for improving safety in radiation oncology (RO) clinics, but few reports focus on the causes of errors in RO. The goal of this study was to test a causal factor taxonomy developed in 2012 by the American Association of Physicists in Medicine and adopted for use in the RO: Incident Learning System (RO-ILS). Methods and materials Three hundred event reports were randomly selected from an institutional ILS database and Safety in Radiation Oncology (SAFRON), an international ILS. The reports were split into 3 groups of 100 events each: low-risk institutional, high-risk institutional, and SAFRON. Three raters retrospectively analyzed each event for contributing factors using the American Association of Physicists in Medicine taxonomy. Results No events were described by a single causal factor (median, 7). The causal factor taxonomy was found to be applicable for all events, but 4 causal factors were not described in the taxonomy: linear accelerator failure (n = 3), hardware/equipment failure (n = 2), failure to follow through with a quality improvement intervention (n = 1), and workflow documentation was misleading (n = 1). The most common causal factor categories contributing to events were similar in all event types. The most common specific causal factor to contribute to events was a "slip causing physical error." Poor human factors engineering was the only causal factor found to contribute more frequently to high-risk institutional versus low-risk institutional events. Conclusions The taxonomy in the study was found to be applicable for all events and may be useful in root cause analyses and future studies. Communication and human behaviors were the most common errors affecting all types of events. Poor human factors engineering was found to specifically contribute to high-risk more than low-risk institutional events, and may represent a strategy for reducing errors in all types of events.

Retroperitoneal sarcomas (RPS) are rare malignancies, comprising just 10-15 % of all soft-tissue sarcomas. These are challenging tumors to treat, with surgical resection being the only modality capable of providing a cure. This study analyzed the management and survival of patients resected at a large academic institution.A retrospective study of all patients with primary localized RPS referred to the University of Washington between January 2000 and January 2013 was performed. Univariate and multivariate Cox regression models were used to analyze progression-free survival (PFS) and overall survival (OS) by patient, tumor, and treatment variables.The study identified 132 patients. Median follow-up was 31.8 months. Median PFS was 33 months, and median OS was 111 months. Sixty patients (45.5 %) underwent a margin-negative resection (R0), 59 (44.7 %) had a microscopic margin-positive resection (R1), and 7 (5.3 %) had a macroscopic margin-positive resection (R2). Forty (30.3 %) patients received preoperative radiation, 28 (21.2 %) received neoadjuvant chemotherapy, and 7 (5.3 %) received both. Tumor grade and microscopic margin status emerged as statistically significant predictors for both PFS and OS. Tumor size was also found to correlate with PFS. No significant difference in OS or PFS was observed for histologic subtype, neoadjuvant chemotherapy, or neoadjuvant radiation.Complete surgical resection should remain the mainstay of management for RPS, with emphasis on achieving negative microscopic margins. Neither neoadjuvant chemotherapy nor radiation was shown to significantly improve survival, and their unclear role in the management of RPS requires evaluation in a prospective setting.

Purpose Despite increasing interest in incident learning systems (ILS) to improve safety and quality in radiation oncology, little is known about interventions developed in response to safety data. We used total body irradiation (TBI) as a model system to study the effectiveness of interventions from our institutional ILS. Methods and materials Near-miss event reports specific to TBI were identified from a departmental ILS from March 2012 to December 2015. The near-miss risk index was rated at multidisciplinary review from 0 (no potential harm) to 4 (critical potential harm). Interventions were analyzed for effectiveness with a schema adapted from The Joint Commission and other agencies: "most reliable" (eg, forcing functions, automation), "somewhat reliable" (eg, checklists, standardization), and "least reliable" (eg, training, rules, procedures). Causal factors of each event were drawn from the casual factor schema used in radiation oncology ILS. Results Of 4007 safety-related reports, 266 reports pertained to TBI. TBI reports had a somewhat higher proportion of high-risk events (near-miss risk index 3-4) compared with non-TBI reports (25% vs 17%, P = .0045). A total of 117 interventions were implemented. The reliability indicators for the interventions were: most reliable (11% of interventions), somewhat reliable (17%), and least reliable (72%). Interventions were more likely to be applied to high-risk events (54% vs 41%, P = .03). There was a pattern of high-reliability interventions with increased risk score of events. Events involving human error (eg, slips) and equipment/information technology lent themselves more often to high-reliability interventions. Events related to communication, standardization, and training were associated with low-reliability interventions. Conclusions Over a 3.5-year period, 117 quality improvement strategies were developed for TBI based on ILS. Interventions were more likely to be applied to high-risk events and high-risk events were more likely to be associated with high-quality interventions. These results may be useful to institutions seeking to develop interventions based on ILS data.

Purpose The safety and quality of radiation therapy have recently garnered increased attention in radiation oncology (RO). Although patient safety guidelines expect physicians and physicists to lead clinical safety and quality improvement (QI) programs, trainees' level of exposure to patient safety concepts during training is unknown. Methods and materials We surveyed active medical and physics RO residents in North America in February 2016. Survey questions involved demographics and program characteristics, exposure to patient safety topics, and residents' attitude regarding their safety education. Results Responses were collected from 139 of 690 (20%) medical and 56 of 248 (23%) physics RO residents. More than 60% of residents had no exposure or only informal exposure to incident learning systems (ILS), root cause analysis, failure mode and effects analysis (FMEA), and the concepts of human factors engineering. Medical residents had less exposure to FMEA than physics residents, and fewer medical than physics residents felt confident in leading FMEA in clinic. Only 27% of residents felt that patient safety training was adequate in their program. Experiential learning through practical workshops was the most desired educational modality, preferred over web-based learning. Residents training in departments with ILS had greater exposure to patient safety concepts and felt more confident leading clinical patient safety and QI programs than residents training in departments without an ILS. Conclusions The survey results show that most residents have no or only informal exposure to important patient safety and QI concepts and do not feel confident leading clinical safety programs. This represents a gaping need in RO resident education. Educational programs such as these can be naturally developed as part of an incident learning program that focuses on near-miss events. Future research should assess the needs of RO program directors to develop effective RO patient safety and QI training programs.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, performance measurement and feedback, which is a common intervention in health professions education. In the form of a summary report, performance measurement and feedback is an opportunity for clinicians to view data about the care they provide compared with some standard and often with peer and benchmark comparisons. Based on a review of recent evidence and a facilitated discussion with the US and Canadian experts, we describe proper terminology for performance measurement and feedback and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report efforts with performance measurement and feedback. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of performance measurement and feedback.

To conduct a nationwide survey to evaluate the current status of resident mentorship in radiation oncology.An anonymous electronic questionnaire was sent to all residents and recent graduates at US Accreditation Council for Graduate Medical Education-accredited radiation oncology residency programs, identified in the member directory of the Association of Residents in Radiation Oncology. Factors predictive of having a mentor and satisfaction with the mentorship experience were identified using univariate and multivariate analyses.The survey response rate was 25%, with 85% of respondents reporting that mentorship plays a critical role in residency training, whereas only 53% had a current mentor. Larger programs (≥ 10 faculty, P=.004; and ≥ 10 residents, P.001) were more likely to offer a formal mentorship program, which makes it more likely for residents to have an active mentor (88% vs 44%). Residents in a formal mentoring program reported being more satisfied with the overall mentorship experience (univariate odds ratio 8.77, P.001; multivariate odds ratio 5, P.001). On multivariate analysis, women were less likely to be satisfied with the mentorship experience.This is the first survey focusing on the status of residency mentorship in radiation oncology. Our survey highlights the unmet need for mentorship in residency programs.

Purpose Radiation treatment planning is a complex process with potential for error. We hypothesized that shorter time from simulation to treatment would result in rushed work and higher incidence of errors. We examined treatment planning factors predictive for near-miss events. Methods and materials Treatments delivered from March 2012 through October 2014 were analyzed. Near-miss events were prospectively recorded and coded for severity on a 0 to 4 scale; only grade 3-4 (potentially severe/critical) events were studied in this report. For 4 treatment types (3-dimensional conformal, intensity modulated radiation therapy, stereotactic body radiation therapy [SBRT], neutron), logistic regression was performed to test influence of treatment planning time and clinical variables on near-miss events. Results There were 2257 treatment courses during the study period, with 322 grade 3-4 near-miss events. SBRT treatments had more frequent events than the other 3 treatment types (18% vs 11%, P = .04). For the 3-dimensional conformal group (1354 treatments), univariate analysis showed several factors predictive of near-miss events: longer time from simulation to first treatment ( P = .01), treatment of primary site versus metastasis ( P P P = .002). However, on multivariate regression only pediatric versus adult patient remained predictive of events ( P = 0.02). For the intensity modulated radiation therapy, SBRT, and neutron groups, time between simulation and first treatment was not found to be predictive of near-miss events on univariate or multivariate regression. Conclusions When controlling for treatment technique and other clinical factors, there was no relationship between time spent in radiation treatment planning and near-miss events. SBRT and pediatric treatments were more error-prone, indicating that clinical and technical complexity of treatments should be taken into account when targeting safety interventions.

There is a growing interest in the application of incident learning systems (ILS) to radiation oncology. The purpose of the present study is to define statistical metrics that may serve as benchmarks for successful operation of an incident learning system.A departmental safety and quality ILS was developed to monitor errors, near-miss events, and process improvement suggestions. Event reports were reviewed by a multiprofessional quality improvement committee. Events were scored by a near-miss risk index (NMRI) and categorized by event point of origination and discovery. Reporting trends were analyzed over a 2-year period, including total number and rates of events reported, users reporting, NMRI, and event origination and discovery.A total of 1897 reports were evaluated (1.0 reports/patient, 0.9 reports/unique treatment course). Participation in the ILS increased as demonstrated by total events (2.1 additional reports/month) and unique users (0.5 new users/month). Sixteen percent of reports had an NMRI of 0 (none), 42% had an NMRI of 1 (mild), 25% had an NMRI of 2 (moderate), 12% had an NMRI of 3 (severe), and 5% had an NMRI of 4 (critical). Event NMRI showed a significant decrease in the first 6 months (1.68-1.42, P.001). Trends in origination and discovery of reports were broadly distributed between radiation therapy process steps and staff groups. The highest risk events originated in imaging for treatment planning (NMRI = 2.0 ± 1.1; P.0001) and were detected in on-treatment quality management (NMRI = 1.7 ± 1.1; P = .003).Over the initial 2-year period of ILS operation, rates of reporting increased, staff participation increased, and NMRI of reported events declined. These data mirror previously reported findings of improvement in safety culture endpoints. These metrics may be useful for other institutions seeking to create or evaluate their own ILS.

Merkel cell carcinoma (MCC) is an aggressive, polyomavirus-associated cancer with limited therapeutic options for metastatic disease. Cytotoxic chemotherapy is associated with high response rates, but responses are seldom durable and toxicity is considerable. Here, we report our experience with palliative single-fraction radiotherapy (SFRT) in patients with metastatic MCC. We conducted retrospective analyses of safety and efficacy outcomes in patients that received SFRT (8 Gy) to MCC metastases between 2010 and 2013. Twenty-six patients were treated with SFRT to 93 MCC tumors located in diverse sites that included skin, lymph nodes, and visceral organs. Objective responses were observed in 94% of the measurable irradiated tumors (86/92). Complete responses were observed in 45% of tumors (including bulky tumors up to 16 cm). “In field” lesion control was durable with no progression in 77% (69/89) of treated tumors during median follow-up of 277 days among 16 living patients. Clinically significant toxicity was seen in only two patients who had transient side effects. An exploratory analysis suggested a higher rate of in-field progression in patients with an immunosuppressive comorbidity or prior recent chemotherapy versus those without (30% and 9%, respectively; P = 0.03). Use of SFRT in palliating MCC patients was associated with an excellent in field control rate and durable responses at treated sites, and with minimal toxicity. SFRT may represent a convenient and appealing alternative to systemic chemotherapy for palliation, for which most patients with oligometastatic MCC are eligible. SFRT may also synergize with emerging systemic immune stimulants by lowering tumor burden and enhancing presentation of viral/tumor antigens.

Introduction: Innovative technology has led to high-precision radiation therapy that has dramatically altered the practice of radiation oncology. This qualitative study explored the implementation of this innovation into practice from the perspective of the practitioners in a large academic radiation medicine program and aimed to improve understanding of and facilitate the educational process of this change. Methods: Multiprofession staff participated in a series of seven focus groups and nine in-depth interviews, and the descriptive data from the transcripts were analyzed using grounded theory methodology. Results: Practitioners believed that there had been a major effect on many aspects of their practice. The team structure supported the adoption of change. The technology changed the way the practices worked. Learning new skills increased workload and stress but led to a new conception of the discipline and the generation of new practice-based knowledge. When the concepts were examined longitudinally, a four-step process of learning was identified. In step 1, there was anxiety as staff acquired the skills to use the technology. Step 2 involved learning to interpret new findings and images, experiencing uncertainty until new perspectives developed. Step 3 involved questioning assumptions and critical reflection, which resulted in new understanding. The final step 4 identified a process of constructing new knowledge through research, development, and dialogue within the profession. Discussion: These findings expand our understanding of how practice-based learning occurs in the context of change and can guide learning activities appropriate to each stage.

Image-guided radiation therapy (IGRT) technologies have had a major impact on many aspects of radiation therapy, from planning to verification and delivery. IGRT has also increased the education and training requirements of the health professionals who work in the field and must learn the new knowledge and skills associated with IGRT approaches. These new skills and knowledge can affect the organization of clinical practice, shifting responsibilities, which, in turn, alter the traditional team structure and dynamics. In particular, IGRT technologies and the new information they bring has markedly changed radiation therapists' professional roles. This phenomenon is explored in a review of practice change concepts and illustrated by an examination of 1 institution's experience during the broad implementation of IGRT.

Background Formulating questions is fundamental to the daily life of a healthcare worker and is a defining characteristic of professional competence and meaningful learning. With high expectations for healthcare providers to remain up-to-date with current evidence and the movement towards formalizing reflective practice as part of physician revalidation, it is important that curricula developed for improving the ability to formulate well-constructed questions are based on the best evidence. Objectives To assess the effectiveness of interventions for increasing the frequency and quality of questions formulated by healthcare providers in practice and the context of self-directed learning. Search methods We obtained studies from searches of electronic bibliographic databases, and supplemented these with handsearching, checking reference lists, and consultation with experts. Selection criteria We considered published and unpublished randomized controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time-series (ITS), and controlled before-after (CBA) studies of any language examining interventions for increasing the quality and frequency of questions formulated by health professionals involved with direct patient care. Data collection and analysis Two review authors independently undertook all relevancy screening and 'Risk of bias' assessment in duplicate. Intervention characteristics, follow-up intervals, and measurement outcomes were diverse and precluded quantitative analysis. We have summarized data descriptively. Main results Searches identified four studies examining interventions to improve question formulation in healthcare professionals. Interventions were mostly multi-component, limited within the context of EBM and primarily in physician and resident populations. We did not identify studies examining changes in frequency of questions formulated or those within the context of reflection. Risk of bias was generally rated to be ‘high risk’. Three of the four studies showed improvements in question formulation in physicians, residents, or mixed allied health populations in the short- to moderate term follow up. Only one study examined sustainability of effects at one year and reported that skills had eroded over time. Authors' conclusions Evidence from our review suggests that interventions to increase the quality of questions formulated in practice produce mixed results at both short- (immediately following intervention), and moderate-term follow up (up to nine months), comparatively. Although three studies reported effectiveness estimates of an educational intervention for increasing the quality of question formulation within the short term, only one study examined the effectiveness in the longer term (one year) and revealed that search skills had eroded over time. Data suggests that sustainability of effects from educational interventions for question formulation are unknown.