Oncology education in Canadian undergraduate and postgraduate medical programs: a survey of educators and learners

Original Articles

Oncology Education

Oncology education in Canadian undergraduate and postgraduate medical programs: a survey of educators and learners


V.C. Tam , BSc(Hon) MD * , S. Berry , MD MHSc , T. Hsu , MD , S. North , MD MHPE § , A. Neville , BMed Biol(Path) MBChB MEd , K. Chan , MD MSc MSc # , S. Verma , MD MSEd

*Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB.
Division of Hematology and Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON.
Division of Medical Oncology, University of Toronto, Toronto, ON.
§Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB.
Department of Oncology, McMaster University, Hamilton, ON.
#Division of Medical Oncology and Hematology, Princess Margaret Hospital, University of Toronto, Toronto, ON.


doi: http://dx.doi.org/10.3747/co.21.1667


ABSTRACT

Background

The oncology education framework currently in use in Canadian medical training programs is unknown, and the needs of learners have not been fully assessed to determine whether they are adequately prepared to manage patients with cancer.

Methods

To assess the oncology education framework currently in use at Canadian medical schools and residency training programs for family ( fm ) and internal medicine ( im ), and to evaluate opinions about the content and utility of standard oncology education objectives, a Web survey was designed and sent to educators and learners. The survey recipients included undergraduate medical education curriculum committee members ( umeccm s), directors of fm and im programs, oncologists, medical students, and fm and im residents.

Results

Survey responses were received from 677 educators and learners. Oncology education was felt to be inadequate in their respective programs by 58% of umeccm s, 57% of fm program directors, and 50% of im program directors. For learners, oncology education was thought to be inadequate by 67% of medical students, 86% of fm residents, and 63% of im residents. When comparing teaching of medical subspecialty–related diseases, all groups agreed that their trainees were least prepared to manage patients with cancer. A standard set of oncology objectives was thought to be possibly or definitely useful for undergraduate learners by 59% of respondents overall and by 61% of postgraduate learners.

Conclusions

Oncology education in Canadian undergraduate and postgraduate fm and im training programs are currently thought to be inadequate by a majority of educators and learners. Developing a standard set of oncology objectives might address the needs of learners.

KEYWORDS: Oncology education , Canada , undergraduate medical programs , postgraduate medical programs

1. INTRODUCTION

Cancer is now the leading cause of death in Canada, and it is estimated that 40% of Canadians will develop cancer in their lifetime1. As a consequence, most physicians will be involved in the management of patients with problems related to cancer or its treatment. Medical students who go on to pursue careers in family medicine ( fm ) or internal medicine ( im ) will frequently be involved in the screening, diagnosis, and follow-up of cancer patients2. Despite those likely responsibilities, there is a deficiency of focused oncology teaching during medical school and fm and im training3. As a result, many medical students and residents have been found to lack the proper knowledge to assist patients in basic cancer prevention and detection even after completion of their training4.

The purpose of the present study was to determine the opinions of educators and learners about the oncology education framework currently used in Canadian medical training programs and to assess their views about the educational needs of medical students and of fm and im residents in preparation for their future involvement in the care of cancer patients.

2. METHODS

Our study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board, the University of Calgary Conjoint Health Research Ethics Board, and the University of British Columbia Behavioural Research Ethics Board. Data collection was completed in 2011.

2.1  Survey and Data Collection

The survey instrument was developed by reviewing oncology-related learning objectives from the Medical Council of Canada5, the College of Family Physicians of Canada6, the Royal College of Physicians and Surgeons of Canada (Internal Medicine)7, and also the Cancer Council of Australia Ideal Oncology Curriculum for Medical Schools8. The first section of the survey contained questions dealing with the current state of oncology education in the respondent’s training program, including whether a formal oncology curriculum exists and whether objectives are provided. The second section of the survey focused on oncology topics currently taught in the training program and asked respondents to rate the importance of including various oncology topics in a set of standard objectives for their program. Five separate surveys were developed (Appendix a ), each with small modifications for a target group: medical students, undergraduate medical education curriculum committee members ( umeccm s), fm and im program directors, fm and im residents, and oncologists. All surveys were available in both English and French.

The surveys were assessed for face and content validity by a group of 10 educators (8 medical and 2 radiation oncologists, including 2 who were also umeccm s) and 10 learners (2 medical students and 2 fm and 6 im residents). Surveys were amended based on the feedback received.

The associate deans at all 17 Canadian medical schools were contacted by e-mail and asked to forward the survey to their umeccm s and final-year medical students. All Canadian fm and im program directors were also contacted by e-mail and asked both to complete the survey and to distribute it to their final-year residents. Surveys were distributed to medical and radiation oncologists by, respectively, the Canadian Association of Medical Oncologists and the Canadian Association of Radiation Oncology. Contacts who distributed the survey were asked to indicate the total of number of individuals who would receive the survey.

2.2  Statistical Analysis

The Web site http://www.surveymonkey.com was used to conduct the survey. Statistical analysis was performed using the SAS software application (version 9.2: SAS Institute, Cary, NC, U.S.A.), and descriptive statistics were calculated.

3. RESULTS

Table i shows characteristics of the educators and learners who participated in the survey. Surveys were sent to 961 educators and 1966 learners. Responses were received from 677 individuals, for an overall response rate of 23% [159 educators (17% response rate), 518 learners (26% response rate)]. Figure 1 shows the distribution of survey responses from across Canada by group surveyed.

TABLE I   Characteristics of educators and learners surveyed

 

 


 

FIGURE 1 Survey responses by region and group surveyed. umeccm = undergraduate medical education curriculum committee members; fm = family medicine; im = internal medicine.

3.1  Oncology Education in Undergraduate Medical Schools

We received responses from 12 associate deans among the 17 Canadian medical schools contacted; 8 agreed to distribute the survey. Survey responses were received from 19 of 175 umeccm s and 342 of 1005 medical students (11% and 34% response rates respectively). Responses were received from educators and learners in all regions except Atlantic Canada.

Table ii summarizes the state of oncology education at each Canadian medical school as reported by survey respondents. Programs with a small number of respondents (fewer than 5) or for which inconsistent responses were received were excluded if an accurate summary of current oncology teaching could not be determined. Of the 8 undergraduate medical programs, 4 had a separate block or rotation dedicated to oncology, and 5 had oncology objectives. Only 2 medical schools recommended an oncology textbook to their medical students, but students were aware of the recommended textbook at only 1 of the 2 schools.

TABLE II   Oncology education in Canadian medical schools

 

Undergraduate oncology education at their medical school was thought to be inadequate by 58% of umeccm s and 67% of medical students. The umeccm s and medical students both agreed that oncology is the worst-taught medical subspecialty (Table iii). Most of the survey’s suggested oncology topics are taught to more than 80% of Canadian medical students. The oncology topics that medical students believed were not taught as often included principles of radiation therapy (taught to 67% of medical students) and principles of systemic therapy (taught to 72%; full results in Appendix a ).

TABLE III  Rankinga the adequacy of teaching of medical subspecialty-related diseases

 

A standard set of oncology objectives for medical students across Canada was supported by 95% of umeccm s and 91% of medical students (Table iv). A textbook or Web book based on those objectives was supported by 89% of umeccm s and medical students. An online-only educational resource was preferred by 58% of umeccm s and 36% of medical students, but 42% of umeccm s and 55% of medical students supported the availability of both a printed textbook and an online Web book. A voluntary oncology summer school course was less popular: just 16% of medical students stated that they would attend; another 39% would consider attending.

TABLE IV   Opinions regarding potential standard objectives, curriculum, and resources for oncology education

 

Table v shows the 5 most important oncology topics for undergraduate medical training programs. The umeccm s and medical students agreed on only one of their 5 most important oncology topics for medical students: “Breaking bad news.” Appendix a shows a full survey ranking of the importance of various oncology topics.

TABLE V   Top 5 most important topics to be included as oncology education core competencies for learners, by program type

 

3.2  Oncology Education in FM Training Programs

Of 17 fm training program directors, 7 (41% response rate) agreed to participate in the survey. Of 579 fm residents who received the participation request, 95 completed the survey (16% response rate), representing 8 fm training programs (47%).

No Canadian fm training programs had a mandatory oncology rotation, and only 2 had a set of oncology objectives for their learners. No program had an oncology curriculum or recommended an oncology textbook or reference resource to its residents.

Oncology education was thought by 57% of program directors and 86% of residents to be inadequate in their respective fm training programs. The fm program directors believed that their residents were least adequately prepared to manage diseases related to oncology and hematology (Table iii). The fm residents felt that they were least adequately prepared to manage patients with cancer.

Most fm program directors (71%) supported a standard set of oncology objectives for their residents (Table iv), and 93% of fm residents thought that oncology objectives were maybe or definitely useful. An online-only educational resource was supported by 71% of fm program directors and 39% of residents; 29% of program directors and 57% of residents preferred having both a printed textbook and an online Web book.

The fm program directors and residents agreed that “screening for common malignancies” and “principles of palliative care” are among the most important topics for fm residents to learn (Table v).

3.3  Oncology Education in IM Training Programs

Of 17 im program directors, 13 initially agreed to participate in the study, but only 10 completed the survey (59% response rate). Of the 382 im residents who received the survey request, 81 completed the survey (21% response rate), representing 13 im training programs (76%).

Of the 13 im programs, 5 had a mandatory 1-month oncology rotation; another 2 training programs in Quebec required a 2-month oncology rotation. All of the im training programs had oncology objectives. Of the 13 responding programs, 9 reported having an oncology curriculum. None reported recommending an oncology textbook or a reference resource to its residents.

Oncology education in their respective im training program was thought by 50% of program directors and 63% of residents to be inadequate. Training program directors and residents both believed that, upon completion of their training program, internists would be least adequately prepared to manage diseases related to oncology (Table iii).

A standard set of oncology objectives was supported by 70% of im program directors and 53% of im residents. An online-only educational resource was supported by 60% of im program directors and 42% of residents; 30% of program directors and 48% of residents preferred having both a printed textbook and an online Web book (Table iv).

Program directors and residents in im programs agreed on 4 of their top 5 most important topics for im residents to learn: “Common complications of cancer,” “Common complications of cancer treatment,” “General knowledge of lung cancer,” and “General knowledge of colorectal cancer” (Table v).

3.4  Opinions of Oncologists

The 123 oncologists who responded to the survey (16% response rate), included 54 medical oncologists, 67 radiation oncologists, and 2 hematology oncologists. Responses were received from at least 1 oncologist from every Canadian medical school. Oncology education in their undergraduate and postgraduate fm and im training programs was thought by 82% of oncologists to be inadequate. The oncologists also agreed that diseases related to oncology are least adequately taught compared with diseases related to other medical specialties (Table iii). Most oncologists believed that a standard set of oncology objectives and a textbook or Web book based on those objectives would be useful to learners (Table iv).

4. DISCUSSION

Our study is the first to characterize in detail the current state of oncology education in Canadian medical schools and in fm and im residency training programs. The major finding was that a broad selection of Canadian medical educators and learners agreed that, compared with trainees in all other medical subspecialties, their trainees are least adequately prepared to manage patients with cancer. Oncology is a separate topic in the curriculum in only half of undergraduate medical programs. None of the fm residency training programs required a mandatory rotation in oncology, and oncology rotations were required in only 7 of the 13 Canadian im training programs surveyed. Most educators and learners also believed that a standard set of oncology objectives would maybe or definitely be useful for learners (92% educators, 90% learners) and that a textbook or Web book focusing on oncology education for medical students and fm and im residents would be useful.

Our results confirm the findings of an earlier, smaller study of administrators in charge of Canadian undergraduate schools of medicine, nursing, pharmacy, and postgraduate resident training programs3. The education leaders in that study also believed that the level of oncology education in their respective programs at that time was inadequate. The inadequacy of preparation is not surprising given that many programs did not have a dedicated oncology curriculum or rotation. Our results are also consistent with those in a study that surveyed medical school deans from 14 European countries. That study, which was conducted by the European Organisation for Research and Treatment of Cancer, found that only 41% of schools had a curriculum in oncology11. A more recent study from the United Kingdom showed that new graduates from U.K. medical schools lacked adequate knowledge about cancer and symptom control12. Only 40% of respondents felt prepared to look after patients with cancer, and 61% would have preferred more teaching in oncology.

One potential solution, which has been instituted in Europe, is the development of summer-school oncology programs for medical students1315. Summer school might not be a viable solution in Canada, given that only 16% of responding Canadian medical students indicated that they would attend a summer school course in oncology. In addition, several medical schools in Canada, such as McMaster University and the University of Calgary, do not have summer breaks. Their students would not have an opportunity to attend summer-school courses.

Although the quantity of oncology teaching might be slightly less than ideal, fragmentation of oncology teaching and the actual information taught are also part of the problem. Of the oncology topics identified in our survey, most were taught to the medical students and residents, but most of the learners nevertheless felt inadequately prepared for their role in managing cancer patients. Encouraging focused coverage of oncology at all levels of medical training and approaching the teaching from the perspective of the knowledge that family physicians and internists will have to acquire for their role in caring for patients with cancer might help to more adequately prepare Canada’s future physicians for clinical practice.

Our study addresses the issue of inadequate oncology education by offering potential solutions to the problem. In Canada, medical schools and residency training programs across the country use various methods of teaching; a single standard Canadian oncology curriculum might be impractical. However, a standard set of oncology objectives for each of the three learner groups could be created using the topics identified as important in this study, together with existing objectives, curricula, and syllabi from each Canadian medical training program. A common set of Canadian oncology objectives for each learner group could supplement existing oncology teaching, increase the consistency of oncology education across the country, and decrease the fragmentation of oncology education in the respective training programs. The new objectives might also serve as a starting point for the development of an oncology education textbook or Web book resource for medical students and fm and im residents.

Our study does have certain limitations. We were not able to obtain responses from educators and learners in all Canadian medical schools and residency training programs. Response rates from certain groups of educators and learners in the medical training programs that we were able to survey were lower than those in other studies3,12. Response rates from umeccm s and oncologists were lower because we were not allowed to contact those groups directly and had to rely on a third party to forward the survey link and subsequent reminder message. By contrast, we obtained response rates of 41% and 76% for fm and im training program directors, whom we were able to contact directly. The 34% response rate from medical students is consistent with rates in other multi-institutional undergraduate oncology education surveys12. However, despite the lower response rates from some groups, we were able to summarize the experiences and opinions of 677 educators and learners in Canada. Our major finding about the inadequacy of preparation in oncology was robust across many universities and training levels. However, an additional limitation was the discrepancies noted between educators and learners and also between individual learners from the same training program about their oncology teaching. Those differences might be secondary to a discrepancy between what educators believe is being taught and what learners say or perceive they are actually experiencing. In addition, individual learners from the same program may have had different experiences during their training.

5. CONCLUSIONS

Oncology education in Canadian undergraduate and postgraduate fm and im training programs is currently thought to be inadequate by a majority of educators and learners. The development of a standard set of oncology objectives focused on topics believed to be most important by educators and based on the needs of learners might improve oncology education for learners and thereby improve the ability of future physicians to care for cancer patients.

6. ACKNOWLEDGMENTS

This study was funded by a University of Calgary Starter Grant and was presented in part at the Canadian Association of Medical Oncology Annual Meeting; Toronto, Ontario; April 26–27, 2012. VCT was funded by a Canadian Association of Medical Oncologists/Canadian Institutes of Health Research Rx&D Research Fellowship Award.

7. CONFLICT OF INTEREST DISCLOSURES

The authors have no financial conflicts of interest to declare.

SURVEY INSTRUMENTS

APPENDIX A:

TABLE A.1   Undergraduate medical curriculum committee survey

 

TABLE A.2   Family medicine and internal medicine program director survey


 

TABLE A.3   Oncologist survey


 

TABLE A.4   Medical student survey

 

TABLE A.5   Family medicine and internal medicine resident survey

 

TABLE A.6   Oncology education topics currently taught in Canadian medical training programs

 

TABLE A.7   Ranking of most important topics to be included as oncology education core competencies for learners in Canadian medical training programs

 

8. REFERENCES

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4. Geller AC, Prout MN, Miller DR, et al. Evaluation of a cancer prevention and detection curriculum for medical students. Prev Med 2002;35:78–86.
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5. Medical Council of Canada (mcc). Objectives for the Qualifying Examination [Web resource]. Ottawa, ON: mcc; 2012. [Most recent version available at: http://apps.mcc.ca/Objectives_Online/objectives.pl?lang=english&loc=home; cited July 1, 2012]

6. The College of Family Physicians of Canada (cfpc). The Evaluation Objectives in Family Medicine. Mississauga, ON: cfpc; 2010. [Available online at: http://www.cfpc.ca/uploadedFiles/Education/Priority%20Topics%20and%20KFs%20with%20skills%20and%20phases%20Jan%202011.pdf; cited July 1, 2012]

7. The Royal College of Physicians and Surgeons of Canada (rcpsc). Objectives of Training in the Specialty of Internal Medicine. Ottawa, ON: rcpsc; 2011. [Available online at: http://www.royalcollege.ca/cs/groups/public/documents/document/y2vk/mdaw/~edisp/tztest3rcpsced000910.pdf; cited July 1, 2012]

8. The Cancer Council Australia. Ideal Oncology Curriculum for Medical Schools: Knowledge, Skills and Attitudes of Medical Students at Graduation. Sydney, Australia: The Cancer Council Australia; 2007. [Available online at: http://www.cancer.org.au/content/pdf/HealthProfessionals/OncologyEducation/IdealOncologyCurricDEC07-updatedcover.pdf; cited July 1, 2012]

9. Shah A. Essentials of Clinical Oncology. 2nd ed. Vancouver, BC: Somerset Publishers; 2008.

10. Griggs JJ, Burtress BA, Khorana AA, Lantz PM, Todd RF. Section X: oncologic disease. In: Andreoli TE, Benjamin I, Griggs RC, Wing EJ, eds. Andreoli and Carpenter’s Cecil Essentials of Medicine. 8th ed. Toronto, ON: Elsevier Canada; 2010.

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14. Haagedoorn EM, Oldhoff J, Bender W. Report of an international summer school—oncology for medical students—in 1996 in Groningen, The Netherlands. J Cancer Educ 1997;12:56–8.
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Correspondence to: Vincent C. Tam, Tom Baker Cancer Centre, 1331 29th Street NW, Calgary, Alberta T2N 4N2. E-mail: vincent.tam@albertahealthservices.ca

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Current Oncology , VOLUME 21 , NUMBER 1 , FEBRUARY 2014








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