Problems in undergraduate medical / nursing / dental cancer education

WHO-CCCE Statements

1. Education = preparation for practice.
2. Undergraduate cancer education should primarily be aimed at the needs of all future medical / nursing / dental / health care professionals.

Introduction

Undergraduate medical / nursing / dental cancer education is an issue that still needs profound attention. The major problems of cancer education are related to the multidisciplinary and multiprofessional nature of oncology, resulting in particular educational problems. This multidisciplinary nature of oncology - and in many cases also the multiprofessional nature - is in many teaching programmes not yet reflected in cancer education. For example: in most curricula lung cancer is a topic that is separately taught in different curriculum years by a general practitioner, a pulmonologist, a pathologist, a surgeon, a radiation oncologist and a medical oncologist; and often without any coordination. It has been demonstrated that such a structure harbours the danger of unnecessary duplications and unnoticed omissions, and is usually complicated by the use of ambiguous medical terminology. The result is a fragmented and confusing presentation of knowledge to students.^1-4

Favourable and unfavourable characteristics in undergraduate cancer education

Several international surveys in the past 30 years have identified favourable and unfavourable characteristics in undergraduate cancer education.^2-5

Favourable institutional characteristics have been identified among others as:

• A curriculum with sufficient flexibility in planning and sufficient elective periods, in order to encourage a broad variety of cancer experience.
• A disease-oriented educational curriculum, permitting a multidisciplinary cancer course or section of a course during the preclinical years.
• A cancer education coordinator and a multidisciplinary cancer education committee with access to a source of funds specifically designated for cancer education activities.
• Representation of the cancer education programme on the school's curriculum committee.
• A system of curricular evaluation with contribution from faculty and students.
• The existence of a mechanism for curricular change permitting innovations when evaluation indicates an unmet need.
• A sufficiently large and motivated faculty representing all relevant cancer-related basic science and clinical disciplines.

Unfavourable institutional characteristics have been identified among others as:

• Condensed basic science courses, minimal or none clinical elective periods.
• A rigidly departmentalized curriculum with faculty exhibiting "territorial imperatives" and reluctance to participate in interdepartmental integrated activities.
• An organ system curriculum in which cancer-related material fragmented system by system, thereby complicating the presentation of general principles of cancer pathobiology.
• A small, overcommitted faculty, lacking one or more key cancer specialists, whose patient care, research, and other teaching responsibilities preclude expansion of cancer education activities.
• Lack of a cancer education coordinator to facilitate innovative multidisciplinary cancer education activities.
• T he absence of a curricular evaluation system of individuals responsible for such evaluation pertaining to cancer education.
• Lack of representation of the cancer education programme on the school's curriculum committee, or lack of a close working relationship of the cancer education coordinator with the Dean's office.
• Clinical facilities which sequester cancer patients away from sites of required clerkship teaching, or which lack inpatients with primary common malignancies and/or cured outpatients, or outpatients with long, generally satisfactory courses.

Developments in health care education

In medical / nursing / dental education there are many developments in progress due to:

• A growing insight that health care education should offer a better preparation for general practice.
• Criticism of general practitioners, nurses and dentists that the medical / nursing dental schools did not train them for knowledge and skills needed in general health care.
• Ministries of health and insurance companies becoming more and more critical concerning health care, with a major concern of financial implications.
• The general public and patient associations becoming more and more critical and assertive concerning health care.
• Students becoming more and more critical concerning the quality of education.

Education = Preparation for Practice

The vast majority of patients who have a (possible) malignant disease are first seen by doctors and dentists who are not specifically trained in oncology. However, those health professionals are an extremely important link in obtaining better results from treatment of cancer through early recognition and through appropriate referral or competent primary treatment. They are also involved in supportive and palliative care for cancer patients.

Medical, dental and nursing schools train future health care professionals of whom the vast majority will choose a non-oncology discipline. But whatever discipline they choose, they will always see patients who (may) have cancer. Therefore the main issues in undergraduate cancer education should primarily be aimed at the needs of all future health care professionals.

Disproportionate education

Instead of teaching medical, nursing and dental students mainly clinical cancer knowledge and skills that are relevant in their future practice, undergraduate cancer education is often dominated by detailed basic science topics such as cellular and molecular biology, detailed staging data of all tumours, pharmacology of cancer drugs, and treatment protocols. In other words: undergraduate students are often predominantly confronted with specialist cancer knowledge.

Consequence

As a consequence cancer care is frequently not recognized by students as an important area of medicine that will prepare them for a substantial part of patient care in general practice. However, the necessity for health care students of any form of clinical exposure to persons with cancer in daily-life situations has been demonstrated repeatedly.

Current problems

In undergraduate cancer education traditional teaching patterns are still commonplace, including that:

• During clinical training students, medical students in particular, are mainly confronted with patients with advanced disease who receive cancer drug treatment, often as part of a clinical research protocol.
• Students, medical and dental students in particular, are seldom confronted with early recognition and cured patients in the outpatient clinics.
• Student-patient encounters seem to be highly dependent on individual teachers and individual students.⁶

Cancer education coordinator

Thus, a prerequisite in cancer education is the presence of a cancer education coordinator who is the core of the cancer education programme, who takes care of the programming, implementation, execution and evaluation of the programme. Another prerequisite is a structured programme with a gradual increase of complexity in which duplications, omissions, and ambiguous terminology can be avoided.

Needs assessment

Needs assessment is the basis for selecting the content of any cancer course or curriculum. Needs assessment leads to relevant topic selection. Needs-assessment is different for medical doctors, nurses and dentists, but there are clinical overlaps. We will here focus on topic selection for cancer care by general medical doctors not specifically-specialized in oncology; and for general specialists not specifically-specialized or specializing in oncology.

Topic selection in cancer education

The undergraduate curriculum programme should focus on what students will have to know before graduating as a medical doctor or as a general specialist not specifically-specialized or specializing in oncology.^7,8

General medical doctors

• Early recognition of particular malignant diseases, with a special focus on crucial questions such as: when to be on the alert for cancer.
• Competence in taking a cancer history; physical examination related to malignant diseases of the head and neck area, lymph node regions, thorax/abdomen, breasts, testicles; pelvic examination including the rectum, prostate, uterus and ovaries; neurological and orthopaedic examination.
• Do's and don'ts.
• Knowledge of required first simple investigations.
• Insight into the need for staging.
• Insight into the relationships between pathology, stage of the disease, prognosis.
• Knowledge of referral strategies.
• Understanding the decision for treatment aimed at cure or aimed at palliation.
• Palliative and supportive care.
• Cancer pain management.
• Communication with patients and relatives.
• Insight in psychosocial care.
• Knowledge of screening techniques and prevention.

General specialists not specifically-specialized or specializing in oncology.

In addition to the above mentioned and depending on the variety of medical disciplines, the following items Simple and advanced investigations.

• Biopsy techniques.
• Staging procedures.
• Pathology and prognosis.
• Treatment options (surgery, chemotherapy, radiotherapy) of tumours with a high incidence.
• Decision making whether treatment can be aimed at cure, or should be aimed at palliation.
• When to refer to cancer specialists.

Precious teaching time

As to the opinion of the WHO-CCCE it is of deep concern that in undergraduate cancer education the emphasis is frequently still on detailed specialist cancer knowledge instead of on topics that are relevant in general practice for all health care professionals. Especially in undergraduate cancer education it should be realised that we need our precious teaching hours for issues relevant for general practice.⁹

References

1. Bakemeier RF,Black GS, Deegan J Jr: Cancer Education Survey: Medical Students and cancer education in U.S. Medical Schools. Vol. 4. DHHS Publication No. 81-2258. Bethesda, Maryland: Nat Inst of Health (1981)
   
2. Bakemeier RF et al: Cancer Education Survey: Summary of observations made during Institutional Visits to 44 U.S. Medical Schools. Vol. 5. DHHS Publication No. 81-2259. Bethesda, Maryland: Nat Inst of Health (1981)
   
3. Bakemeier RF et al: Cancer Education Survey: Final Report, Cancer Education in U.S. Medical Schools. Vol. 6. DHHS Publication No. 81-2259. Bethesda, Maryland: Nat Inst of Health (1981)
   
4. Haagedoorn EL. Thesis: Aspects of Cancer Education for Professionals. Groningen University Faculty of Medicine, Groningen, the Netherlands. Published by Haagedoorn EL, printed by Mondeel B.V. Amsterdam. 1985.
   
5. EORTC Document "Bonn Curriculum" Revised document 1998. Project of the EORTC Education and Training Division, Supported by the European Commission DG V / File No: SOC 96 200656 05F02.
   
6. Bender W, Haagedoorn EML, Oldhoff J. Cancer Education in Europe according to Medical Faculty and Medical Students. Report, Second WHO/UICC Survey on Undergraduate Medical Cancer Education in Europe (1991/1992). Groningen, the Netherlands, WHO Collaborating Centre for Cancer Education. 1993; 34 pg. [Excerpted version on this website : see under projects]
   
7. Haagedoorn EML, Vries de J. Topic selection in undergraduate medical cancer education and relevance to general practice. J Cancer Educ. 1998;13:137-140
   
8. J. de Vries. Essentials in Cancer Education. J Cancer Educ. 1999;14(4):194-198
   
9. Haagedoorn EML, Oldhoff J, Bender W: Verslag van een onderwijsproject aan de Faculteit der Geneeskunde, Rijksuniversiteit Groningen. Groningen, juli 1991. Internal publication Groningen University Faculty of Medicine.