Oncology education for internal medicine residents: a call for action!

Editorial

Oncology education for internal medicine residents: a call for action!


T. Younis, MBBCh*, B. Colwell, MD*


doi: http://dx.doi.org/10.3747/co.25.4046

Cancer is a prevalent health condition that all physicians will frequently encounter during their clinical practice. Indeed, 1 in 2 Canadians will be diagnosed with cancer during their lifetime, and 1 in 4 will die of cancer1. Furthermore, cancer survivors represent a significant and growing population within every physician’s practice. Adequate oncology education for trainees, in the undergraduate (medical students) and graduate (residency training) settings, and continuous medical education for practicing physicians (oncologists and non-oncologists), is therefore essential for optimal health care in Canada and elsewhere. Nonetheless, in a prior study published in Current Oncology by Tam et al.2, oncology was identified, compared with 9 other medical subspecialties, by both internal medicine residents and program directors as the least adequately taught subspecialty. In that study, oncology education was described as being “inadequate” by 58% of undergraduate educators and 67% of medical students, by 57% of family medicine program directors and 86% of family medicine residents, and by 50% of internal medicine program directors and 63% of internal medicine residents.

In this issue of Current Oncology, Nixon et al.3 attempt to elucidate the value for internal medicine residents in Canada of participation in a medical oncology elective rotation. The investigators conducted an online survey over a 3-year period (2013–2015), for all internal medicine residents before and after their medical oncology rotation at 4 Canadian teaching cancer centres. The surveyed internal medicine residents showed statistically significant improvements in their comfort level in dealing with cancer patients (to 4.0/5 from 3.2/5, p < 0.001) and with patients at end of life (to 4.0/5 from 3.6/5, p = 0.003), and in cancer knowledge assessments (mean score: 83% post-rotation vs. 76% pre-rotation; p = 0.003). A number of preferred teaching topics were also identified, including oncologic emergencies, common complications of treatment, approach to the diagnosis of cancer, general cancer treatment principles, and management of common cancers. Perhaps more importantly, 54% of the responding residents felt that medical oncology should be a mandatory rotation during internal medicine training, while 42% believed that it should be a selective rotation, and only 2% believed it should be elective only.

The improvement in oncologic knowledge, and perhaps in generally favourable views, after oncology rotations in this study and others are not surprising35. As an example, in a different study by Chen et al.4, approximately one third of the residents who were required to complete a hematology/oncology rotation at a comprehensive cancer centre also reported improvement in general oncology knowledge after the rotation. More interestingly, it appears that the favourable perception of the oncology specialty by residents might be influenced by the specific setting of their oncologic exposure. In the study by Chen et al.4, most residents reported an improved general opinion of hematology/oncology after their rotation, and a significant proportion were also more motivated to pursue the specialty as a career. Conversely, in a study by McFarland et al.5, residents reported decreased interest in hematology/oncology after spending a rotation on an inpatient hematology/oncology service.

The study by Nixon et al.3 in this issue of Current Oncology has a few limitations. Perhaps most importantly, the results obtained from residents who choose a medical oncology rotation might not be generalizable to all internal medicine residents, including those who might not have been interested in a medical oncology rotation or career (that is, selection bias). The results should also be viewed within the context of the relatively small sample size of responders (34% responders, 66 of 192 residents), a high dropout rate for completion of the post-rotation survey (73% completion rate, 48 of 66 residents), and distribution of the survey only in large academic centres. Notwithstanding those limitations, the investigators should be commended for this novel study that highlights a very relevant topic in today’s oncology education: Should medical oncology become a mandatory rotation for internal medicine residency training programs in Canada?

The recommendation about whether to include medical oncology as a mandatory rotation for internal medicine residents should reflect both the breadth of oncology knowledge required for graduating internal medicine residents, taking into account their chosen career paths (whether general internal medicine or a particular subspecialty), and the adequacy of medical oncology teaching provided in non-oncology medicine rotations. With respect to the former goal, an individual’s future exposure to oncology patients will obviously vary with the specialty chosen. As an example, the oncology knowledge required for physicians in subspecialty practice could be different depending on whether the subspecialty involves short, procedure-oriented encounters (for example, interventional cardiology) or long-term ongoing care (for example, geriatrics). With respect to the latter goal, it is unrealistic to expect that the current predominant model of oncology teaching for internal medicine residents through general non-oncology rotations, together with didactic lectures and self-study, will adequately address educational objectives and identified needs for oncologic education. Given that the practice of medical oncology has shifted from an inpatient setting to a predominantly outpatient setting, adequate oncology education would have to rely heavily on outpatient oncology-specific settings. Indeed, internal medicine residents at the 4 academic centres surveyed by Nixon et al. spent approximately 80% of their medical oncology rotation in outpatient clinics, which highlights the current oncologic model of care in Canada.

The Royal College of Physicians and Surgeons of Canada provides guidance about the training objectives and requirements for internal medicine residents6. The internal medicine training programs fulfil the stated objectives using various didactic lectures as well as various clinical encounters or rotations. A number of years ago, the College was asked to consider making medical oncology a mandatory rotation; in the end, it decided to eliminate a large number of mandatory subspecialty rotations and to give choice and flexibility to the individual training programs. The current College requirements for subspecialty exposure mandate that internal medicine residency training include 15 selective blocks, or equivalent training, in at least 8 of a list of 20 subspecialties6. Most universities have maintained some control, such that some of the subspecialty subjects are still mandatory. Currently, only 38% of internal medicine training programs have a mandatory medical oncology rotation embedded within the 3-year standard format; most provide either selective or elective medical oncology rotations for interested residents2. That variation might reflect the personal exposure of program directors to oncology during their residency training, or perhaps their perceptions of the importance of oncology training, or even the fact that changing one aspect of training cannot occur in isolation and the status quo will be upset.

The study by Nixon et al. addresses a few important questions, but others remain unanswered. Should oncology rotations be structured primarily during the 1st, 2nd, or even 3rd postgraduate year? What about internal medicine training programs in institutions with no in-house dedicated oncology service? Would a 1-month rotation suffice to provide the required knowledge for all internal medicine residents? Why aren’t many internal medicine residents exposed to adequate oncology training? Is it their choice (because of future career plans) or inability (because of program constraints)? How can training programs fit the oncology rotations within the mandated 3-year training for internal medicine residents, given all other competing rotations and education needs?

The increasing incidence and prevalence of cancer has meant that the disease cannot be overlooked. The practice of oncology has also significantly evolved since the closing years of the 1990s, with an ever-increasing emphasis on outpatient management. The time has come for internal medicine and medical oncology educators to revamp oncology education requirements to ensure adequate exposure of internal medicine residents to common oncologic conditions. Furthermore, an even stronger case could be made for ensuring oncology education for family medicine residents, who will undoubtedly encounter many patients with oncology-related health care issues, and who have self-identified as having inadequate training. As oncologists, we should all ensure that our future non-oncologist colleagues acquire oncologic knowledge adequate to allow them to optimally care for cancer patients and survivors in their chosen career paths.

ACKNOWLEDGMENTS

The authors are grateful for insightful comments and feedback from Dr. Alwin Jeyakumar, the program director for medical oncology residency training at Dalhousie University, and Dr. Stephanie Snow, the undergraduate director for medical oncology at Dalhousie University.

TY is the assistant clerkship director for internal medicine at Dalhousie University. BC is the current president of the Canadian Association of Medical Oncologists (camo), a previous member of the Royal College’s Medical Oncology Nucleus committee, and a previous program director for the medical oncology residency training program at Dalhousie University. The views presented here are those of the authors and not those of Dalhousie University or camo.

CONFLICT OF INTEREST DISCLOSURES

We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none.

AUTHOR AFFILIATIONS

*Department of Medicine, qeii Health Sciences Centre, and,
Faculty of Medicine, Dalhousie University, Halifax, NS..

REFERENCES

1. Canadian Cancer Society’s Advisory Committee on Cancer Statistics. Canadian Cancer Statistics 2017. Toronto, ON: Canadian Cancer Society; 2017.

2. Tam VC, Berry S, Hsu T, et al. Oncology education in Canadian undergraduate and postgraduate medical programs: a survey of educators and learners. Curr Oncol 2014;21:e75–88.
cross-ref  pmc  

3. Nixon NA, Lim H, Elser C, Ko YJ, Lee-Ying R, Tam VC. Oncology education for Canadian internal medicine residents: the value of participating in a medical oncology elective rotation. Curr Oncol 2018;25:213–18.

4. Chen H, Mortazavi A, Levine E, Kamisetti S, Kamisetti S, Ramnath N. What did you think of the hematology/oncology rotation? A survey of internal medicine residents. J Cancer Educ 2007;22:50–5.
cross-ref  pubmed  

5. McFarland DC, Holland J, Holcombe RF. Inpatient hematology–oncology rotation is associated with a decreased interest in pursuing an oncology career among internal medicine residents. J Oncol Pract 2015;11:289–95.
cross-ref  

6. Royal College of Physicians and Surgeons of Canada (rcpsc). Specialty Training Requirements in Internal Medicine. Ver. 2.0. Ottawa, ON: rcpsc; 2015. [Available online at: http://www.royalcollege.ca/cs/groups/public/documents/document/mdaw/mdg4/~edisp/088402.pdf; cited 22 January 2018]


Correspondence to: Tallal Younis, QEII Health Sciences Centre, 1276 South Park Street, 454 Bethune Building, Dalhousie University, Halifax, Nova Scotia B3H 2Y9. E-mail: tallal.younis@nshealth.ca

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Current Oncology, VOLUME 25, NUMBER 3, June 2018








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ISSN: 1198-0052 (Print) ISSN: 1718-7729 (Online)