Graduate Medical Program – University of Sydney
With the variable, non-uniform curricula in most (medical) schools it was early recognised that some means of determining progress would be most desirable. Thus in 1948 an objective type of evaluation was developed. (Wood 1987)
The idea that oncology education needs constant evaluation, updating and standardisation is not new. In one of the first published investigations of Australian undergraduate cancer education, substantial differences between medical schools were found, primarily in curricula content (Tattersall & Langlands 1993). Subsequent evaluation of cancer education and surveys of medical students’ oncology knowledge and skills have not indicated a high standard of training in these areas (Barton et al. 2003, Tattersall et al. 1988, Smith et al. 1991). Perhaps more disturbing are the results of a comparison of skills of interns in Australia and New Zealand from 1990 and 2001 (Barton et al. 2003). This study found that graduate medical program curricula appear to have successfully introduced new course material and new methods of teaching. However, these programs have not always succeeded in producing doctors with better knowledge about cancer (Barton et al. 2003). This is in the context of an “Ideal Oncology Curriculum” having been developed by The Cancer Council Australia in 1989 (Oncology Education Committee 1999, Tattersall & Langlands 1993). With the changes in the curricula throughout Australian medical schools (eg. graduate medical programs) and the establishment of new medical schools (see below) the opportunity has arisen for curriculum review, as well as the chance to enhance and revitalise teaching in various areas including oncology education. Although ongoing analysis of graduates’ knowledge and skill has been undertaken and the ideal oncology curriculum, teaching resources and programs have been developed (De Vries et al. 2002, Galaycthuk 2000, Geller et al. 2000, Mehta et al. 1998 and Oncology Education Committee 1999), we seem to be going backwards in terms of graduate knowledge and exposure to patients with cancer (Barton et al. 2003). It should be noted that the Australian experience is not unique. Sloan et al. (2000) from United States stated that “there is clearly a vacuum in the area of cancer education” and Biswal et al. (2004) from Malaysia found that undergraduates had profound deficiencies in basic knowledge of cancer and cancer prevention.
Cancer affects one in three Australians, making it an important component of medical education (Koczwara et al. 2005). That cancers should be cured is no longer a Utopian ideal (Jones et al. 2001). It has been estimated that 80-90% of all cancer deaths in developed countries may be preventable through primary prevention and secondary intervention (Zapka et al. 2000). The progress made in medicine over the past century has changed the face of society and the practice of medicine. Patients presenting are now more likely to have chronic disease and require multiple specialist referrals. Alongside these changes (and perhaps because of them) the social contract between doctors and patients has changed along with patient expectations. In addition learning has moved the concept of teaching from “know all” to “know how” (Jones et al. 2001). In recognition of these changes medical education in Australia has undertaken a major overhaul of the delivery of education and selection of students. More changes are to come with the introduction in the next few years of seven new medical schools around the country (Lawson et al. 2004). Clearly there are deficits in the delivery of oncology education, but there are also some exciting opportunities and resources with which to correct these deficits in Australia over the next decade. But how do we best make use of these opportunities?
There are many groups in oncology education, each with their own specific complexities. Each group has something to offer as well as something to gain via an improvement in oncology education in Australia. Who are some of the stakeholders?
‘It is easier to win a war than to change a medical curriculum by even one half hour’ (Chester TE 1975, reported in Kamien 1993). A survey of clinical oncologists and clinicians responsible for cancer teaching in Australian medical schools (Tattersall et al. 1993) indicated that some of the bias and misinformation detected in student’s experience/knowledge1 may be attributed to attitude, knowledge and differences of opinion of the teachers. These authors stated that the curriculum in many Australian medical schools did not reflect the views of cancer teachers but the entrenched attitudes of individual departments guarding their teaching time and turf (Tattersall et al. 1993). The change from didactic segregated teaching along departmental lines (ie. anatomy, physiology, pathology etc) to a faculty wide, problem-based approach constitutes a massive paradigm shift. One benefit from these changes has been that oncology can now be taught as an integrated subject rather than occupy (sometimes piecemeal) parts of other courses of study. Kamien (1993) states that the ‘genius’ of this change (describing McMaster Medical School) lies in “devising a system whereby the curriculum belongs to the school as a whole … it is controlled by an elected committee”. Curriculum reform involves widespread changes and challenges to medical school faculties. It involves a chance to participate in the evolution of medical education locally through evaluation and utilisation of new pedagogic methods eg. portfolio learning (Finlay et al. 1998, Maughan et al. 2001), self-directed learning computer resources (Cameo B) and Building Partnerships Program (Boyle et al. 2002). It also affords the opportunity to align with other medical schools, share experiences, pool data and share resources. This has been the experience of the International Union Against Cancer (UICC) in Sao Paulo Brazil, which expanded successful interventions in oncology education from Sao Paulo throughout other parts of Latin America (Junqueira 2001). The possibility to expand beyond our national borders and help develop oncology education throughout the Asia-Pacific is an exciting possibility.
Patients and Advocacy groups
Despite the recommendations, now almost 20 years old, that “In all Australian Medical Schools a compulsory course in oncology should be established. This topic should be examinable, and the presence of an appropriate course should be a requirement for an accreditation review”, change seems to be slow (Tattersall 1999). The development of the Ideal Oncology Curriculum (Oncology Education Committee 1999) was made possible by the participation and advocacy of cancer patients. Their participation also ensures that the concerns of patients can be met through curricula review.
The nature of a student’s clinical experience has changed, due to the success (in developed countries) of primary prevention and secondary intervention in cancer. This means that medical students in hospitals seldom palpate a breast cancer (Kennedy 1996). Many solutions have been put forward: increased primary care experience, portfolio learning2 (Finlay et al. 1998, Maughan et al. 2001) and community partnerships3 (Henry 1996). All three of these require the participation of the patient population and advocacy groups in order to succeed. This gives power to the patient as educator in this situation, as well as being an invaluable and (in the case of portfolio learning) an already proven method to increase the outcome of oncology education in the undergraduate curriculum (Finlay et al. 1998).
Patients can also share their experiences not only of a diagnosis of cancer, but their treatment both good and bad. This can be communicated directly to the medical community (Blennerhassett 1998, 2001) or to the general public (Hattenstone 1999, Miles 1995). Blennerhassett’s (1998) personal account of anal cancer is one such example, accompanied by a response from Metcalfe (1998) which states that her (Blennerhassett’s) experience can/should act as a catalyst not only to change undergraduate curricula, particularly with regard to communication skills, but also to change current practice. A feedback loop from the ultimate stakeholder, the patient, is central if difficulties such as those experienced by Blennerhassett are to be ameliorated (Jones et al. 2001).
Undoubtedly, “clinicians are our best asset” (Judy Searle, Dean of Medicine Griffith University Qld quoted in Lawson et al. 2004). However, they are also our most stretched resource: huge teaching loads, increasingly complex patient loads and their own continuing medical education must be attended to. More time for teaching means an increased staffing requirement and a higher premium put on time dedicated to teaching by hospital administrations.
Are doctors teachers? Although enshrined in the hippocratic oath, the willingness to teach does not necessarily translate into the ability; how able and equipped are medical practitioners to teach and are we doing much to help them? One example is the Teaching on the Run series (Lake 2004). In the editorial introducing this series Greenberg & Elliot (2004) state that the title highlights two causes of anguish among teachers: lack of time and lack of knowledge of teaching techniques.4 It is interesting to note that one of the published desired learning outcomes of the Scottish Deans Medical Curriculum Group is Communicating as teacher (Simpson et al. 2002). This indicates the importance this group places on equipping future clinicians to be educators.
Students surveyed in 1990 and 2001 showed that recent graduates actually had less exposure to cancer patients than those who trained 10 years ago (Barton et al. 2003). In particular, there is limited information about the place of palliative care in the undergraduate curriculum and what there is indicates that there may be deficits in Australia (Cairns & Yates 2003, Glare & Virik 2001).5
We need to ensure that students are adequately prepared and supported when dealing with issues about cancer, especially terminal cancer, as well as issues of loss experienced by patients during successful treatment of their cancer (Wear 2002). Metcalfe (1998) comments that some of the problems encountered by patients with cancer are due to the paucity of communication skills teaching, the lack of care of students’ feelings when they have to confront severe suffering (so that they defend themselves by dehumanising the patient), inappropriate teaching of ethics and the elitism that characterises undergraduate medical education.
Medical students are starting their training at a later age and this often means they are also starting families at the same time (Kennedy 1997). This has implications for their willingness and/or ability to participate in “after-hours” teaching. It also means that they are, in general a student body with more experience both in the undergraduate experience and life in general. These students also have the ability and responsibility to perceive deficits in their education and lobby for changes. Indeed, an example of this has been reported, a student-run, faculty endorsed and supported, elective introduction to oncology exists in the US (Axelrod & Lowney 1993).6 Selecting older students has been associated with graduates that are more likely to develop an “immune” professional persona (altruistic) when faced with the transition form preclinical to clinical curriculum (Coulehan & Williams 2003).7 This hopefully translates into practitioners who are able to “survive” the grind of medical education with their altruism intact (Coulehan & Williams 2001).
Unification across the above groups of people is the key to making gaps known and developing as well as implementing a solution. This is beginning to happen as can be seen by the make-up of The Cancer Council’s Oncology Education Committee. However, there seems to have been a patchy participation in Australian medical schools of the proffered solution. It has been recently suggested that, for a number of reasons, a national exit exam should be considered for all Australian medical school graduates to ensure standardisation and a basic minimum requirement for hospital practice and internship (Koczwara et al. 2005). An exit exam is one way of ensuring that the message gets through to both medical schools and students alike that there is an expected minimum standard that must be reached. It is imperative that the Oncology Education Committee lobbies for a place at the table should the idea eventuate. Another advantage of an exit exam would be the possibility to evaluate different undergraduate curricula over time and between Australian medical schools with outcomes.
The term “outcome-based” was coined by Donabedian, who developed a paradigm for quality assessment, comprising structure, process and outcome. He recognised that, while some outcomes (such as death) might be easily recognised and measured, others were not. Among the latter he included “patient attitudes and satisfactions, social restoration and physical disability and rehabilitation”. Donabedian suggested that “outcomes by and large, remain the ultimate validators for the effectiveness and quality of medical care” (quoted from Jefford et al. 2003).
According to McNeir (1993) outcomes in education should be broad in vision but specific enough to be taught and measured effectively. Outcomes education is an effort to overcome a situation of inappropriate and excessive testing, unnecessary surgery, a proliferation of medical error and the systematic undervaluing of the humane, holistic and affective components of medicine in favour of the technical, reductionistic, and invasive features (Coulehan & Williams 2003).
Tamblyn et al. (1998) have used outcome research to determine that those who performed better on a standardised patient licensing examination correlated with improved practice patterns, such as appropriate mammographic screening, suggesting that education may be an independent variable in cancer treatment outcomes (Sloan 2000). Such studies as University of Kentucky prospective randomised trials allow us to hypothesise that cancer education can be regarded as an important cancer treatment variable (Sloan 2000).
There are difficulties; Norman (2002) identified three main difficulties in implementing outcome-based research in medical education:
a) real differences in educational strategies may not be reflected in outcomes, such as licensing examination performance, simply because students are highly motivated and not blinded to the intervention, so will compensate for any defects in the curriculum;
b) a curriculum contains many components, delivered with variable quality by different teachers; and
c) time between learning and important outcomes may be so long that the effects of the curriculum are obscured, although not always (Norman 2002). Additionally randomisation, control of variables and choice of appropriate outcome measures (appropriate for the intervention) are all difficult to optimise.
Outcomes-based education has the additional attraction of being able to actively involve all the above mentioned stakeholders as well as government and the wider community. In Australian oncology education we have the benefit of knowing the current level of student competency. Indeed, it has been seen to improve in some areas and decline in others (Tattersall & Langlands 1993, Tattersall 1999, Tattersall et al. 1998, 1993, Barton & Simons 1999, Barton et al. 2003). The Cancer Council Oncology Education Committee has suggested a way forward. Is it time to test it? Could we implement the Ideal Oncology Curriculum state and/or nationwide and test its utility? The benefits of outcomes education is that it can be used as encouragement to implement change as well as a way to continually improve and update the curriculum as changes in the field (both oncology and education) occur.8
Two important elements need thorough exploration before this could be attempted. Firstly, desired outcomes in oncology must be well defined. In the 1998 Shattuck lecture, Ellwood (1998) outlined outcomes management and the idea that cost (time, money, suffering, undergraduate medical education curriculum hours) can be plotted against benefit (lives saved, early detection, pain averted etc.) and that there is a hyperbolic relationship.9 We should, especially in an overcrowded undergraduate medical curriculum, be aiming to get the greatest benefit from our interventions. Prevention and detection are the obvious candidates in oncology education but more generally, interventions aimed at improving communication skills, examination proficiency, pain management skills and evidence-based medicine competency10 would also be candidates. The second and perhaps more difficult issue is how and when to measure specific outcomes which require active participation of all stakeholders and has yet to be clearly defined in the literature (Prideaux 2002).
Outcomes-based education is one possibility for the future of oncology education in Australia, but it should not be used in isolation; qualitative investigations of educational interventions are also invaluable for informing curriculum development (Hays et al. 1988, Sanidas et al. 1993, Wilkerson et al. 2002). This is particularly well done in the specialty of palliative care (Oneschuk 2002, Lasch et al. 2002, Flaherty et al. 2002, Lloyd-Williams & Dogra 2003, Llyod-Williams & Dogra 2004, Shapiro 2002, Wear 2002 and Weinstein et al. 2000).
Oncology education in Australia is currently in a position where the necessary characteristics to implement outcomes based educational interventions in cancer curricula are all present. We have the knowledge and personnel-base to ensure ongoing improvement, and in the future this may be realised as improved outcomes for patients. Oncology in Australia is in the position to lead the future of medical education generally, but could also effect change in our region. We have the funds and expertise to optimise oncology education and in the future the resources with which to help those in the Asia-Pacific.
“To leave education unused as an instrument for change would constitute a disservice to society in general and to our patients in particular.” (Sloan 2000).
*This article is the winning essay in The Cancer Council Australia’s student essay competition. As the winner, Jennifer Anderson attended the World Health Organisation’s Collaborating for Cancer Education’s “Oncology for Medical Students” summer school.
2. Portfolio learning in this context involves following a patient with cancer and their family over 6-12 months supported by regular tutorials and as part of a larger oncology curriculum. Students record triggers to learning including medical history and a diary of interaction with patient and family including reflection (Maughan et al. 2001).
3. Community partnerships aim to enhance education by moving students out of hospitals and into the community. The structures which formalise this partnership between academia and community are committees, with members form the academic institution, community centre and members of the community itself (Henry 1996).
4. This series is not without its critics, in response to the series Majoor and Ibrahim (2004) state that the idea that “any” education will do, and that “anyone” can teach, remains pervasive. The danger of promoting “teaching on the run” is to reinforce the view that teaching is not a specialised discipline that requires specific skills and training.
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