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Devising the Optimal Preclinical Oncology Curriculum for Undergraduate Medical Students in the United States

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Devising the Optimal Preclinical Oncology Curriculum for Undergraduate Medical Students in the United States
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  Devising the Optimal Preclinical Oncology Curriculumfor Undergraduate Medical Students in the United States Nicholas J. DeNunzio  &  Lija Joseph  &  Roxane Handal  & Ankit Agarwal  &  Divya Ahuja  &  Ariel E. Hirsch Published online: 18 May 2013 # Springer Science+Business Media New York 2013 Abstract  A third of women and a near majority of men inthe United States will be diagnosed with cancer in their lifetimes. To prepare future physicians for this reality, wehave developed a preclinical oncology curriculum that intro-duces second-year medical students to essential conceptsand practices in oncology to improve their abilities to ap- propriately care for these patients. We surveyed the oncolo-gy and education literature and compiled subjects important to students' education including basic science and clinicalaspects of oncology and addressing patients' psychosocialneeds. Along with the proposed curriculum content, sched-uling, independent learning exercises, and case studies, wediscuss practical considerations for curriculum implementa-tion based on experience at our institution. Given the chang-ing oncology healthcare landscape, all (new) physiciansmust competently address their cancer patients' needs, re-gardless of chosen specialty. A thorough and logically or-ganized cancer curriculum for preclinical medical studentsshould help achieve these aims. This new model curriculum,with accompanying strategies to evaluate its efforts, is es-sential to update how medical students are educated about cancer. Keywords  Oncology .Curriculum .Undergraduatemedicalstudents .UnitedStates Introduction Undergraduate medical education is the cornerstone for training the next generation of physicians to care for healthyand ailing members of our society. Medical school curricula aim to develop students ’  basic and clinical sciences knowl-edge as well as their professional and clinical skills. Al-though some fields are systems-based, many others, such asoncology, are trans-disciplinary and demand mastery of several topics in parallel.Cancer patients currently compose a significant subset of those seeking medical care. In the United States approximate-ly half of men and a third of women will be diagnosed withcancerduringtheirlifetimes whileabout one infivewilldie of cancer [1]. Furthermore, as projected by the World HealthOrganization, 26 million people worldwide will receive a cancer diagnosis in the year 2030 alone [2]. Therefore, all practicing physicians should be able to diagnose cancer andhave at least a basic appreciation for how to address cancer  patients ’  needs, regardless of whether they will serve as the primary provider or refer the patient to a specialist.Implementing a cancer curriculum for undergraduate med-ical students to address these issues was proposed as early as24 years ago in Europe [3] and addressed more recently byreviewing published teaching efforts [4]. Cancer educationguidelines for undergraduate medical students over the dura-tion of their formal education have been developed in Aus-tralia [5]. However, the Australian recommendations do not  provide council for timely integration of concepts to appro- priately prepare students for each stage of their schooling.A detailed outline of basic science and clinical concepts,as well as social and emotional issues, for training medicaloncologists in the United States [6] is too detailed in manyareas for effectively educating undergraduate medical stu-dents. In addition, few undergraduate medical curricula emphasizing oncology in some capacity are available fromthe Curriculum Management and Information Tool available J Canc Educ (2013) 28:228  –  236DOI 10.1007/s13187-012-0442-0  N. J. DeNunzio :  R. Handal : A. Agarwal : D. Ahuja  : A. E. Hirsch ( * )Department of Radiation Oncology, Boston University Schoolof Medicine, 830 Harrison Avenue, Moakley Building  –   LL,Boston, MA 02118, USAe-mail: Ariel.hirsch@bmc.orgL. JosephDepartment of Pathology and Laboratory Medicine, BostonUniversity School of Medicine, 715 E. Concord Street,Boston, MA 02118, USA  through the Association of American Medical Colleges [7].Consequently, the development of a curriculum specific toundergraduate medical students that exposes students to basic concepts in caring for their cancer patients is essential prior to their clinical rotations [8, 9]. Some medical schools have begun to integrate aspects of cancer curricula into their undergraduate medical educationcourses with specific learning objectives [10, 11]. At our  institution, we have developed a formal preclinical oncologycurriculum for undergraduate medical students to systemat-ically address both traditional basic science coursework andelements essential to providing holistic care to complexcancer patients. Despite the increasingly blurred lines de-marcating preclinical and clinical portions of undergraduatemedical education curricula, preclinical here refers to thefirst two years during which students traditionally spend the bulk of their time in a classroom setting.The revised curriculum proposed here, modeled from that mentioned above, is an attempt at tailoring concepts andmethods in oncology education to fulfill unmet needs. In aneffort to achieve this end, the curriculum addresses many of the requirements deemed important by the Licensing Com-mittee for Medical Education (LCME) for sound develop-ment of an undergraduate medical curriculum [12] as well asmany of the professional competencies emphasized anddeveloped by the Accreditation Council for Graduate Med-ical Education (ACGME; Fig. 1a ) for residency programs[13, 14]. We hope readers find this curriculum and sug- gested evaluation techniques helpful in their efforts to im- prove cancer education domestically and globally. Cancer Education in the United States Existingcancer curricula at some medical schools in the UnitedStates during preclinical education focus differentially on can-cer prevention and cancer survivorship. After the AmericanAssociation for Cancer Education published recommendations based on a Cancer Education Survey of 126 medical schools, a few medical schools made curriculum reforms to increase can-cer preventionand screening education [10].Boston Universityincorporated an additional nine hours of lectures, case-basedlearning, and skills laboratories on cancer prevention andscreening. As a result, self-reported skill level for counselingtobacco cessation, tobacco prevention, sun protection and earlydetectionofbreast,skin,andcervicalcancerincreased[15].TheUniversity of California   –  Los Angeles (UCLA) implemented a similarcurriculum reformand surveyevaluations showedskills practice was the greatest contributor to improvement in cancer  preventionandscreeningcompetencyasperceivedbythestudy participants [11].While there have been multiple advances in the area of cancer prevention and screening, education on survivorshiphas been limited. In fact, a literature search identifiedonly one comprehensive curriculum on the latter topic.It describes a survey and knowledge-based examinationof 211 senior medical students from UCLA, Universityof California   –  San Francisco (UCSF), and Drew Univer-sity that show that 42 % displayed no or incorrect knowledge about basic survivorship terminology and37 % lacked knowledge of essential elements of a comprehensive cancer history. The majority also felt unprepared to manage the long-term care of cancer  patients [16]. In response to this dearth in cancer survivorshipeducation, UCLA, UCSF, and Drew created a four-year inte-grated cancer survivorship curriculum under the NationalCancer Institute Cancer Education Grants Program (R25).The curriculum is based on individual units consisting of lectures, problem-based learning exercises, and standardized patient exercises throughout medical school [17]. However,even this expansive and much-needed curricular innovationfocuses on only cancer survivorship education and in a scat-tered modular style rather than in the style of a dedicated,much more inclusive oncology block. Fig. 1 a  Pie chart depicting the six ACGME competencies fulfilled bygraduate medical education programs.  b  Venn diagram representingour ideal preclinical oncology curriculum ( black rectangle ) that showshow each section develops some or all of the ACGME competencies asshown by inset pie chartsJ Canc Educ (2013) 28:228  –  236 229  How to Make It Happen: Curriculum Design We developed this comprehensive preclinical oncology cur-riculum from the perspectives of patients, caregivers, physi-cians and other healthcare professionals. In decidingwhether a given topic is appropriate for inclusion we con-sidered several factors:Medical KnowledgeBasic and clinical science principles provide a foundationfor understanding epidemiology, carcinogenesis, and princi- ples of surgical, radiation, and systemic treatments. Scien-tific concepts across cancers (e.g., acquired DNA mutations,viral infections, inherited genetic defects) should be inte-grated while avoiding esoteric molecules and signaling pathways. Reinforcing themes and information about spe-cific tumors across lectures that utilize interactive audienceresponse systems provides repetition and student participa-tion to facilitate students ’  pattern recognition and long-termretention [18  –  21]. Framing the information in the context of clinical case discussions prepares students to address prob-lems as practicing physicians. Include topics such as the pathophysiology, methods for detection, and standardapproaches to treatment. Consider emerging and niche tech-nologies and clinical algorithms but relegate any in-depthdiscussion to the third and fourth years.Patient Care, Population StudiesPreclinical medical students need to understand the epidemi-ology of common cancers (gender, genetics, environmentalexposures, socioeconomic status, geographic distribution,etc.) as well as the utility of prevention, lifestyle modification(e.g., smoking cessation) and screening. Exercise, in particu-lar,withits manybenefitsinhealthyandsickindividuals alike[22] provides common approaches to disease prevention andcure and may alleviate psychosocial stressors that contributeto comorbidities like anxiety, depression, and sleeplessness.Given that patient populations may differ significantly,students should be introduced to common cancers but the preclinical oncology curriculum must have flexibility toreflect the training environment, including cancer variantsand the resources at the medical school ’ s principal instruc-tional sites.Patient Care, Psychosocial AspectsTo produce well-rounded and optimally prepared physi-cians, students must consider how the psychosocial ele-ments of a patient  ’ s life influence their access to care,compliance with diagnostic and treatment plans and, ulti-mately, response to treatment. How a patient  ’ s psychosocialstressors should be treated depends on the stressor itself [23]. Overall, the oncology literature on psychosocial stres-sors is not terribly robust [24], but does suggest that variousstressors may amplify morbidity and mortality among can-cer patients. In fact, mind  –   body interactions profoundlyinfluence medical outcomes for some non-cancerous pathol-ogies like irritable bowel syndrome [25].Students should also be introduced to palliative and end-of-life care. They must be competent in giving bad news, pain management and managing terminal illnesses for  patients and their families. Physicians must also be skilledat anticipating and addressing patients ’  psychosocial needsgiven the physical, emotional, financial, and social stressors patients are likely to encounter. Although palliation hastraditionally been reserved exclusively for the weeks or months preceding a patient  ’ s death, attention to symptommanagement is worth pursuing concurrently with activetreatment to increase the quality of life, improve survivaland even reduce healthcare expenditures [26, 27]. Providing  palliative care and support to children and their familiesrequires special expertise and sensitivity [28] and may lie beyond the scope of a more generalized oncology curriculum.Integrating Professionalism and Communication to ImprovePatient CareHow physicians communicate with patients as well as howthey interact with colleagues in coordinating patient care are both important. Medical students must learn to not onlyconsistently relay information to the patient that is directlyrelated to their disease, including treatment plan, prognosis,and future options, but also address their psychosocialneeds, whether for adults [29] or children [30]. Medical students must be trained to deliver bad news professionally but with a humanistic touch. Per Miller  ’ s pyramid for assessing clinical competence, clinical compe-tence is gained in several steps (Fig. 2) [31]. In the oncology  block, small group discussions and mock patient and phy-sician communication sessions (Topics 56  –  58, Table 1) laythe groundwork for the development of these skills, whichthen are further developed during students ’  third and fourth(clinical) years of medical school. Given the complex com-munication required, a single session is insufficient to de-velop this skill. Rather, students must have repeatedopportunities for reflection, synthesis, and practice [13, 14, 32] although breaking bad news to patients need not occur on a topic-specific basis [33]. Therefore, schools have great flexibility in how and when to impart appropriate knowl-edge and experiences during the preclinical years.Physicians must also communicate well with both patients and their colleagues. Certainly, given the largenumber of professionals who care for a single patient, mis-communication (or a lack of communication) is common 230 J Canc Educ (2013) 28:228  –  236  [34] and not just in the treatment of cancer patients [35]. All  patients and specialties would benefit from attention to better interprofessional communication.Based on the aforementioned considerations we developedsix learning objectives to guide curriculum design and topics(Table 2). How to Make It Happen: Implementationand Follow-Up Interspersed Discussions vs. Modular/Block Format A given curriculum may be taught in a variety of ways.Preclinical courses may be organized by scientific discipline,organsystem,orclinicalspecialty.Oncologycanbeintegratedinto that of other systems modules (e.g., pathology and clin-ical presentation of pancreatic adenocarcinoma within thegastrointestinal system) or relegated to an oncology-centric block or module. We and others [4] believe that the block format, welcomed by the students who have progressedthrough and reflected upon it at our institution (unpublisheddata), is more effective to cohesively present integrated mate-rial that may otherwise be lost if dispersed throughout theentire preclinical undergraduate medical curriculum. The onestudy comparing student perceptions of interspersed discus-sions integrated throughout the curriculum compared to a modular format on specific subjects that a literature searchrevealed showed that students in the interspersed discussionstylecurriculumaresignificantlylesssatisfiedwiththequalityand quantity of their education on a given subject matter compared to the modular curriculum model [36].A consolidated cancer curriculum is particularly helpfulin introducing topics that are essential in treating manycancers but may not warrant significant attention whendiscussing any single pathology. Lectures on the principlesof surgical, chemotherapeutic, and radiation treatments areoften lost in an interspersed format. The lack of emphasis onradiation oncology in the undergraduate medical curriculumand strategies to address this issue were recently reviewed[37, 38]. This is worrisome given that nearly 60 % of all cancer patients receive radiotherapy as part of their treat-ment regimens [39]. Students ’  understanding of the under-lying principles and patterns among cancers and their treatments can be lost in the absence of an oncology block strategy.If an interspersed cancer curriculum must be employed, a director or small team of faculty (to include, e.g., medical,surgical, and radiation oncologists, psychiatrists, as well asallied health professionals) should provide oversight.The interspersed curriculum could also be supplementedwith the consolidated block towards the end of the preclin-ical years if time permits. As such, the implementation of  both approaches would allow for repetition, which wouldenhance retention as well as comprehension.Sample ScheduleTo efficiently incorporate the basic tenets outlined into a cohesive program of study for undergraduate medical stu-dents, we provide an outline of an oncology block adaptedfrom the current version in use at the Boston UniversitySchool of Medicine (BUSM; Table 1). BUSM Preclinical Oncology Block  Since its inception in 2009, our preclinical oncology block has exposed students to basic science and clinical conceptsin oncology as part of our horizontally integrated OncologyEducation Initiative (OEI) [40]. Scientific lectures are pairedwith those relating to clinical aspects of a given disease or group of diseases. For example, lectures 20, 29, and 35 aredevoted to the pathology of lung, genitourinary, and breast cancers, respectively, while 21, 30, and 36 discuss theepidemiology, clinical presentations, effective diagnosticmodalities, therapeutic options, and preferred treatment reg-imens. Students thus appreciate how intricately biomedicalresearch and clinical care are intertwined.A dedicated oncology block provides several opportuni-ties for curricular integration. Indeed, schools are investi-gating vertical and horizontal integration of disciplines inresponse to blurred lines demarcating traditional disciplinessecondary to an ever-evolving medical knowledge base [41,42]. At BUSM, gross anatomy, histology, pathology, radi-ology and oncology are integrated and discussed in a small-group format in the designated oncology block. Studentsrotate through stations of radiology images to develop dif-ferential diagnoses before viewing gross and microscopicfeatures of classic neoplasia. Data are also posted online for students to study independently. Since BUSM uses digitalmicroscopy to teach histology, each of these sessions is also Fig. 2  Miller  ’ s pyramid of clinical competence. The oncology block  proposed here relies on the three base levels while relegating the toplevel to clinical studies in the later years of medical schoolJ Canc Educ (2013) 28:228  –  236 231

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