Medical Teacher, Vol. 14, No. 4, 1992
347
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
A review of the oncology curriculum at Dalhousie medical school
RON MAcCORMICK~,GERARD CORSTEN**, P. J. FITZPATRICKf 81 JOHN ALDRICHf *Oncology Clinic, Saudi Arabian Oil Company Medical Organization, **Dalhousie University, Halifax, Nova Scotia, fCancer Treatment and Research Foundation, 5820 University Avenue, Halifax, Nova Scotia B3H 1 V7
SUMMARY The teaching of oncology at Dalhousie medical school is currently lefi to the discretion of the 30 university departments. There is no central coordination. This organization leaves no monitoring of curriculum content to see that what should be covered is indeed covered, nor does it provide teaching from the perspective of oncology rather than the perspective of the other individual disciplines. Following an inventory of the oncology curriculum and a survey of interns graduating from Dalhousie in 1991, we recognize deficiencies in the clinical portion of the curriculum that could be rectified with a small number of hours designed to teach the various aspects of the management of cancer patients in case-scenario, student participation sessions.
Introduction The importance of cancer as a cause of morbidity and mortality continues to grow in western society, and this importance is also reflected in our medical education system. With this in mind, Dalhousie University appointed a review committee to look at the teaching of oncology in the undergraduate program. From this committee came the idea of conducting an inventory of the oncology curriculum to examine what is being taught as compared to an idealized curriculum, and to recommend any changes to improve the students’ expertise in dealing with cancer patients following graduation. At Dalhousie, no course in oncology per se exists, as topics in oncology are taught within the curricula of the 30 departments. This organization means that prior to the This work was carried out at the Cancer Treatment and Research Foundation in Halifax, Nova Scotia, through funding generously provided by the Dalhousie University Department of Radiation Oncology.
348
Ron MacCormick et al.
formation of the oncology curriculum review committee, no-one was responsible for monitoring to see that topics in oncology were covered in the curriculum or ensuring that all topics of an idealized curriculum were covered without excessive duplication. Furthermore, this organization causes the material concerning oncology to be spread out through many courses, leaving the student very disorganized concerning oncology topics. In addition, each department is concerned primarily with teaching how oncology topics interact with their specialty, instead of teaching cancer patient care with a more generalized view.
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
Methodology In order to determine where deficiencies lie in the oncology curriculum, a comprehensive inventory of the current teaching was necessary. Before starting this project, an idea of what should be taught to some idealized curriculum was necessary. We started with an outline produced by the European Organization for the Treatment and Research of Cancer (EORTC), which did work in 1988 to formulate a standard oncology curriculum in European Medical Schools (EORTC, 1988). After modifying the EORTC topic list slightly, a basic outline listing the topics that would form a basic minimum of topics which must be covered in the undergraduate teaching of oncology was produced. This topic list is provided in Appendix 1. Surveys were then sent to the department heads of each of the 30 departments teaching at Dalhousie medical school, asking them to give a description of any lectures, tutorials, clinical teaching or other materials relating to oncology that they taught in their course. The department heads were also asked to identify those topics on the curriculum outline which were covered by their teaching. T o supplement these descriptions, copies of handouts given to students or lecture notes were obtained whenever possible. Much of this information was stored on a computer database to simplify data analysis. From this survey, descriptions of the contributions of all the courses to the topics in our curriculum topic list were compiled and examined to identify any duplication among courses or topics that were not covered sufficiently by any course. The second part of this study included a survey of recent graduates from Dalhousie. Members of the graduating class of 1991 that were interning in the Halifax area were asked to fill out a short questionnaire revealing their opinions on various aspects of the teaching of oncology in their 4 years at Dalhousie. Questions covered such topics as the organization of teaching material, opportunities for electives, quality of coverage of various topics in oncology, and the ability of Dalhousie to prepare the student for cancer patient management. Thirty-four questionnaires were sent, with 25 of these returned from the various interns. The questions asked and results of the questionnaire are found in Appendix 2. Results Course organization
The survey of the interns showed that many students do not like the current organization of the course. While fewer than 50% felt that material was duplicated, or felt insufficient time was devoted to oncology, 80% of respondents felt that the material was disorganized and felt that it was spread through too many different
Oncology at Dalhousie medical school
349
courses. Several students, in their comments, suggested a course in oncology or finding some way to bring the material together in a more organized fashion. These negative comments could be expected, considering the format of oncology teaching at Dalhousie. Dalhousie is in the minority of medical schools in Canada in not having a designated course in oncology or some department or curriculum committee organizing the content of oncology teaching (see Shibata, 1984). This lack of unifying factor was obviously noticed by the students.
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
The basic science cum.culum
In looking at the topics from our topic list that were covered by the various courses, the basic science portion of the oncology course seems to be well covered, overall. All of the topics listed in our basic curriculum topic list (Appendix 1) were identified as covered by multiple departmental lectures, and most topics had at least one department that covered the topic with a generalized outlook. This competent coverage of material may be attributed to the fact that several courses, especially pathology, biochemistry and blood devote hours to a generalized view of basic science topics in oncology. The intern survey tended to support his view, as the basic science topics listed on the survey were described as well covered by a large percentage of the respondents (70-90%), with the basic science topics receiving a more favorable review than the clinical topics (see Appendix 2 for results of the survey).
The clinical cum’culum The clinical portion of the curriculum is where some deficiencies in teaching seem to lie. Several intern suggestions made references to increasing teaching in the clinical aspects of oncology. Also, the topics receiving the lowest percentage of favorable reviews by the interns were all clinical in nature. For example, only 18% of interns surveyed felt that the teaching of multidisciplinary cancer patient management was taught well. Multidisciplinary management of patients, methods of early diagnosis, and use of imaging methods and endoscopy were three topics that received the worst reviews by interns asked how well these topic were covered. Some clinical topics received favourable reviews: tumor classification, direct patient contact, pain management and palliative care. (Appendix 2 contains a complete breakdown of these figures). These deficiencies in the clinical portion could be in part due to a lack of any general teaching in oncology. In the departmental descriptions of their teaching material, it became clear that all the teachings were narrow in scope, dealing all too often with oncology only as it relates to the particular specialty being taught. For example, surgery would teach about surgical procedures for patients with cancer, but would not address more generalized topics such as the process to decide on whether surgical or other therapies (such as medical or radiation therapy) would be more suitable for a particular patient. Overall, the curriculum seemed to lack teaching in the areas of treatment decision-making, methods of early diagnosis, and the role of clinical trials in oncology. Also, multidisciplinary management of cancer patients is not given sufficient coverage.
350
Ron MacCormick et al.
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
Discussion Our review demonstrated that, overall, all the elements of an oncology curriculum are present. However, students have no ‘feel’ for the care of cancer patients. Within the framework of the existing curriculum, this ‘feel’ or overview of oncology could be generated by the investment of a small number of additional hours in a problem-solving, clinically-oriented student participation session. For our own purposes we recommend the addition of approximately 10 hours to the existing curriculum. Several of these hours can be taken from areas of duplication recognized by our oncology curriculum inventory. Suggested scenarios could take simple yet common problems, such as the approach to a breast lump, and follow it up from science to diagnostic procedures, treatment decision making, treatment procedures, follow-up care, palliative care, and family counseling. Our present methodology of curriculum development is based on perceptions of what is being taught (the curriculum inventory) versus perceptions of what is taught (the recent graduate survey). This approach in a curriculum review is, in effect, a gapfiller rather than a complete restarting of a curriculum.
Conclusion Our curriculum inventory and survey of interns provides an insight into the present state of the oncology curriculum at Dalhousie University medical school. From it, we were able to identify deficiencies and duplications in our delivered curriculum. Also, we were able to identify areas of inadequacy as perceived by recent graduates. Our suggestion of the addition of a few hours devoted to clinically-oriented problem-solving sessions would add little strain to our curriculum and improve the “feel” for oncology, while encouraging further learning in oncology in keeping with the goals of life-long learning the modern medical curriculum seeks to foster (see Tosteson, 1990).
Correspondence: Gerard Corsten, Cancer Treatment and Research Foundation, 5820 University Avenue, Halifax, Nova Scotia, B3H 1V7. REFERENCES EUROPEAN ORGANIZATION FOR THE TREATMENT AND RESEARCHOF CANCER(1988) A Curriculum in Oncology for Medical Students in Europe (1988) (EC/EORTC report). SHIBATA, H.R. (1984) Undergraduate Teaching of Oncology in Canadian Medical Schools (A report to the Canadian Oncology Society). TOSTESON, D.C. (1990) New Pathways in General Medical Education, The N m England Journal of Medicine, 4, p. 234.
Appendix 1: Checklist of topics in an idealized oncology curriculum Scientific basis of oncology (A) The nature of cancer (a) Malignant transformations (b) Changes in the cell genome (c) Biochemistry of carcinogenesis
Oncology at Dalhousie medical school (d) Biological characteristics (e) Regulation of growth & differentiation ( f ) Oncogenes, growth factors and receptors
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
(B) The cause of cancer (a) Lifestyle (tobacco, diet, UV radiation, alcohol) (b) Environmental (c) Carcinogenesis (chemical, nutritional, physical) (d) Genetics (e) Tumor virology ( f ) Primary prevention (C) The behavior of cancer (a) Histology, morbid anatomy (b) Infiltration & metastases (c) Cell kinetics & growth characteristics (d) Hormone dependence (e) Immunology ( f ) Differentiation (tumor) markers
(D) Descriptive epidemiology (a) (b) (c) (d) (e) (f) (8) (h)
Methods of registration Incidence, age, sex Geographical features Prevention Lifestyle, social behavior Risk factors Statistics (survival analysis) Screening
Clinical teaching (E) Diagnosis (a) Specific aspects relating to a cancer history (b) Specific aspects of physical examination (common cancers & their mode of spread) (c) The importance of ‘performance status’ (d) Biochemical tests as tumor markers (e) Methods of imaging (radiology, isotopes, ultrasound, MRI) and endoscopy (f) Biopsy and cytology (9) Awareness of potentials and limitations of above methods
(F) Clinical staging (a) (b) (c) (d)
Classification system ( T M N classification of malignant tumors) Diagnostic procedures Biological tumor markers Prognostic factors
(G) Management
(a) (b) (c) (d) (e) (f) (8) (h) (i) (j)
Principles of surgery, radiotherapy, & medical cancer treatment Concepts of cure (end points) Concepts of palliation Management of pain Quality of life Hospital care vs. home care Terminal care Communication with patients, relatives, other health professionals Role of doctors in public education Community assets (societies, support groups, etc.)
(H) Psychology (a) Patient and family counseling (b) Psychosocial support
35 1
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Ron MacCormick et al.
(I) Clinical trials (a) Methodology (b) Ethics (c) Limitations
(J) Practical training (a) Especially in areas of practical skills and early diagnosis
(K) Practical diagnosis (a) (b) (c) (d) (e)
Direct exposure to patients & taking a cancer history Methods of early diagnosis & palpation of lumps Oral, vaginal & rectal examinations Cervical smear Cytology
(L) Multi-disciplinary management of the main tumor types
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
(a) Common cancers, especially those that are curable
Appendix 2: Intern survey and results Twenty-four interns responded to this survey out of a possible 32 surveys sent to the various Dalhousie graduates who were interning in the meter0 area this summer. 1) Regarding your four years of undergraduate training at Dalhousie, do you agree with any of the following statements about the Oncology curriculum: (a) (b) (c) (d) (e) (f)
Insufficient total time devoted to oncology Duplication of material in different courses Inappropriate emphasis of material Outdated material taught Material disorganized Material spread out through too many different courses
2) Are there adequate opportunities to pursue electives in the jield of oncology?
Y 44% ( 1 1 ) Y 46% (12) Y 40% (10) Y 37% (9) Y 80% (19) Y 80%(19)
N 56% (14) N 54% (13) N 60%(15) N 63% (15) N 20% (6) N 2 0 % (6)
Y 65% (15)
N 35% (8)
Do you plan to specialize in any aspects of oncology? Definitely 0% Strong possibility 0% Slight possibility 40% (10)
N o 60% (15)
3) Where do you feel you have gained most of your knowledge and experience in the jield of oncology (i.e. which courses or rotations)? In clerkship 4 Gynecology 8 D&B 2 Surgery 10 Pathology 8 Urology 4 EENT 1 Medicine 5 Respirology 2 Electives 5 4) After four years of medicine, how prepared for the management of a cancer patient do you feel? (rate your preparedness on a scale of I to 4) 4 =completely prepared, 1 =insufficiently prepared 40% 3:47% ( 1 1 ) 2.5:13% (3) 2:40% (9) 1:0%
5) To what extent wereyou exposed to thefollowing topics duringyourfouryears at medical school at Dalhousie? 3 =covered well, 2 =covered minimally, 1 =not covered Biology of cancers in terms of cell kinetics, oncogenes, and growth factors 2.512% (3) 2:24% (6) 1:0% 3:64% (16) The causes of cancer (carcinogens, genetics, environment) 2.5:8% (2) 2:12% (3) 1:0% 3:80% (20) Infiltration and metastases 3:64% (16) 2:28% (7) 1:8% (2) Epidemiology of cancer 3:84% (21) 2 5 8 % (2) 2:0% 1:8%(2)
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
Oncology at Dalhousie medical school
353
Cancer screening 3 5 2 % (13) 2:44% (11) 1:4% (1) Methods of imaging (radiology, isotopes, ultrasound, MRI) and endoscopy 2.5: 13% (3) 2:74% (17) 1:0% 3:13% ( 3 ) Classification of tumors (TMN system) 3:50% (12) 2:50% (12) 1:0% Principles of surgery, radiotherapy, and medical cancer treatment 3:33% (8) 2 5 8 % (2) 258% (14) 1:0% Palliative care 350% (12) 2:46% (11) 1:4% (1) Pain management 3:68% (15) 2.5:14% (3) 2:18% (4) 1:0% Psychosocial support for the patient and family 3:42% (10) 250% (1 2) 1:8% (2) Direct exposure to patients with cancer 3:41% (9) 2514% ( 3 ) 2:36% (8) 1:9% (2) Methods of early diagnosis 3:25% (6) 2.5:8% (2) 2:64% (14) 1:8% (2) Interactions between many disciplines in the management of a cancer patient 3:18% (4) 2.5:9% (2) 2:64% (14) 1:18% (4) 6 ) Do you have any specijic suggestions as to ways in which the oncology curriculum at Dalhousie could be
improved? 0 More emphasis on practical aspects of patient care. 0 A course in oncology would be good. Above would make an ideal course. 0 Increase time in early detection and pain management. 0 Follow 1-2 patients through a year of medical school, learning how they were diagnosed and managed. 0 Students should have more exposure to cancer patients early in their career. 0 Bring it together in a more organized fashion. 0 More appropriate lectures on chemo/radiation therapy overall for a cancer. 0 More exposure to palliative care in geriatrics. 0 More small group teaching in med IWIV. 0 Extend duration of medical school by 1 year to include several important areas that do not get curriculum time.
347
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
A review of the oncology curriculum at Dalhousie medical school
RON MAcCORMICK~,GERARD CORSTEN**, P. J. FITZPATRICKf 81 JOHN ALDRICHf *Oncology Clinic, Saudi Arabian Oil Company Medical Organization, **Dalhousie University, Halifax, Nova Scotia, fCancer Treatment and Research Foundation, 5820 University Avenue, Halifax, Nova Scotia B3H 1 V7
SUMMARY The teaching of oncology at Dalhousie medical school is currently lefi to the discretion of the 30 university departments. There is no central coordination. This organization leaves no monitoring of curriculum content to see that what should be covered is indeed covered, nor does it provide teaching from the perspective of oncology rather than the perspective of the other individual disciplines. Following an inventory of the oncology curriculum and a survey of interns graduating from Dalhousie in 1991, we recognize deficiencies in the clinical portion of the curriculum that could be rectified with a small number of hours designed to teach the various aspects of the management of cancer patients in case-scenario, student participation sessions.
Introduction The importance of cancer as a cause of morbidity and mortality continues to grow in western society, and this importance is also reflected in our medical education system. With this in mind, Dalhousie University appointed a review committee to look at the teaching of oncology in the undergraduate program. From this committee came the idea of conducting an inventory of the oncology curriculum to examine what is being taught as compared to an idealized curriculum, and to recommend any changes to improve the students’ expertise in dealing with cancer patients following graduation. At Dalhousie, no course in oncology per se exists, as topics in oncology are taught within the curricula of the 30 departments. This organization means that prior to the This work was carried out at the Cancer Treatment and Research Foundation in Halifax, Nova Scotia, through funding generously provided by the Dalhousie University Department of Radiation Oncology.
348
Ron MacCormick et al.
formation of the oncology curriculum review committee, no-one was responsible for monitoring to see that topics in oncology were covered in the curriculum or ensuring that all topics of an idealized curriculum were covered without excessive duplication. Furthermore, this organization causes the material concerning oncology to be spread out through many courses, leaving the student very disorganized concerning oncology topics. In addition, each department is concerned primarily with teaching how oncology topics interact with their specialty, instead of teaching cancer patient care with a more generalized view.
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
Methodology In order to determine where deficiencies lie in the oncology curriculum, a comprehensive inventory of the current teaching was necessary. Before starting this project, an idea of what should be taught to some idealized curriculum was necessary. We started with an outline produced by the European Organization for the Treatment and Research of Cancer (EORTC), which did work in 1988 to formulate a standard oncology curriculum in European Medical Schools (EORTC, 1988). After modifying the EORTC topic list slightly, a basic outline listing the topics that would form a basic minimum of topics which must be covered in the undergraduate teaching of oncology was produced. This topic list is provided in Appendix 1. Surveys were then sent to the department heads of each of the 30 departments teaching at Dalhousie medical school, asking them to give a description of any lectures, tutorials, clinical teaching or other materials relating to oncology that they taught in their course. The department heads were also asked to identify those topics on the curriculum outline which were covered by their teaching. T o supplement these descriptions, copies of handouts given to students or lecture notes were obtained whenever possible. Much of this information was stored on a computer database to simplify data analysis. From this survey, descriptions of the contributions of all the courses to the topics in our curriculum topic list were compiled and examined to identify any duplication among courses or topics that were not covered sufficiently by any course. The second part of this study included a survey of recent graduates from Dalhousie. Members of the graduating class of 1991 that were interning in the Halifax area were asked to fill out a short questionnaire revealing their opinions on various aspects of the teaching of oncology in their 4 years at Dalhousie. Questions covered such topics as the organization of teaching material, opportunities for electives, quality of coverage of various topics in oncology, and the ability of Dalhousie to prepare the student for cancer patient management. Thirty-four questionnaires were sent, with 25 of these returned from the various interns. The questions asked and results of the questionnaire are found in Appendix 2. Results Course organization
The survey of the interns showed that many students do not like the current organization of the course. While fewer than 50% felt that material was duplicated, or felt insufficient time was devoted to oncology, 80% of respondents felt that the material was disorganized and felt that it was spread through too many different
Oncology at Dalhousie medical school
349
courses. Several students, in their comments, suggested a course in oncology or finding some way to bring the material together in a more organized fashion. These negative comments could be expected, considering the format of oncology teaching at Dalhousie. Dalhousie is in the minority of medical schools in Canada in not having a designated course in oncology or some department or curriculum committee organizing the content of oncology teaching (see Shibata, 1984). This lack of unifying factor was obviously noticed by the students.
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
The basic science cum.culum
In looking at the topics from our topic list that were covered by the various courses, the basic science portion of the oncology course seems to be well covered, overall. All of the topics listed in our basic curriculum topic list (Appendix 1) were identified as covered by multiple departmental lectures, and most topics had at least one department that covered the topic with a generalized outlook. This competent coverage of material may be attributed to the fact that several courses, especially pathology, biochemistry and blood devote hours to a generalized view of basic science topics in oncology. The intern survey tended to support his view, as the basic science topics listed on the survey were described as well covered by a large percentage of the respondents (70-90%), with the basic science topics receiving a more favorable review than the clinical topics (see Appendix 2 for results of the survey).
The clinical cum’culum The clinical portion of the curriculum is where some deficiencies in teaching seem to lie. Several intern suggestions made references to increasing teaching in the clinical aspects of oncology. Also, the topics receiving the lowest percentage of favorable reviews by the interns were all clinical in nature. For example, only 18% of interns surveyed felt that the teaching of multidisciplinary cancer patient management was taught well. Multidisciplinary management of patients, methods of early diagnosis, and use of imaging methods and endoscopy were three topics that received the worst reviews by interns asked how well these topic were covered. Some clinical topics received favourable reviews: tumor classification, direct patient contact, pain management and palliative care. (Appendix 2 contains a complete breakdown of these figures). These deficiencies in the clinical portion could be in part due to a lack of any general teaching in oncology. In the departmental descriptions of their teaching material, it became clear that all the teachings were narrow in scope, dealing all too often with oncology only as it relates to the particular specialty being taught. For example, surgery would teach about surgical procedures for patients with cancer, but would not address more generalized topics such as the process to decide on whether surgical or other therapies (such as medical or radiation therapy) would be more suitable for a particular patient. Overall, the curriculum seemed to lack teaching in the areas of treatment decision-making, methods of early diagnosis, and the role of clinical trials in oncology. Also, multidisciplinary management of cancer patients is not given sufficient coverage.
350
Ron MacCormick et al.
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
Discussion Our review demonstrated that, overall, all the elements of an oncology curriculum are present. However, students have no ‘feel’ for the care of cancer patients. Within the framework of the existing curriculum, this ‘feel’ or overview of oncology could be generated by the investment of a small number of additional hours in a problem-solving, clinically-oriented student participation session. For our own purposes we recommend the addition of approximately 10 hours to the existing curriculum. Several of these hours can be taken from areas of duplication recognized by our oncology curriculum inventory. Suggested scenarios could take simple yet common problems, such as the approach to a breast lump, and follow it up from science to diagnostic procedures, treatment decision making, treatment procedures, follow-up care, palliative care, and family counseling. Our present methodology of curriculum development is based on perceptions of what is being taught (the curriculum inventory) versus perceptions of what is taught (the recent graduate survey). This approach in a curriculum review is, in effect, a gapfiller rather than a complete restarting of a curriculum.
Conclusion Our curriculum inventory and survey of interns provides an insight into the present state of the oncology curriculum at Dalhousie University medical school. From it, we were able to identify deficiencies and duplications in our delivered curriculum. Also, we were able to identify areas of inadequacy as perceived by recent graduates. Our suggestion of the addition of a few hours devoted to clinically-oriented problem-solving sessions would add little strain to our curriculum and improve the “feel” for oncology, while encouraging further learning in oncology in keeping with the goals of life-long learning the modern medical curriculum seeks to foster (see Tosteson, 1990).
Correspondence: Gerard Corsten, Cancer Treatment and Research Foundation, 5820 University Avenue, Halifax, Nova Scotia, B3H 1V7. REFERENCES EUROPEAN ORGANIZATION FOR THE TREATMENT AND RESEARCHOF CANCER(1988) A Curriculum in Oncology for Medical Students in Europe (1988) (EC/EORTC report). SHIBATA, H.R. (1984) Undergraduate Teaching of Oncology in Canadian Medical Schools (A report to the Canadian Oncology Society). TOSTESON, D.C. (1990) New Pathways in General Medical Education, The N m England Journal of Medicine, 4, p. 234.
Appendix 1: Checklist of topics in an idealized oncology curriculum Scientific basis of oncology (A) The nature of cancer (a) Malignant transformations (b) Changes in the cell genome (c) Biochemistry of carcinogenesis
Oncology at Dalhousie medical school (d) Biological characteristics (e) Regulation of growth & differentiation ( f ) Oncogenes, growth factors and receptors
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
(B) The cause of cancer (a) Lifestyle (tobacco, diet, UV radiation, alcohol) (b) Environmental (c) Carcinogenesis (chemical, nutritional, physical) (d) Genetics (e) Tumor virology ( f ) Primary prevention (C) The behavior of cancer (a) Histology, morbid anatomy (b) Infiltration & metastases (c) Cell kinetics & growth characteristics (d) Hormone dependence (e) Immunology ( f ) Differentiation (tumor) markers
(D) Descriptive epidemiology (a) (b) (c) (d) (e) (f) (8) (h)
Methods of registration Incidence, age, sex Geographical features Prevention Lifestyle, social behavior Risk factors Statistics (survival analysis) Screening
Clinical teaching (E) Diagnosis (a) Specific aspects relating to a cancer history (b) Specific aspects of physical examination (common cancers & their mode of spread) (c) The importance of ‘performance status’ (d) Biochemical tests as tumor markers (e) Methods of imaging (radiology, isotopes, ultrasound, MRI) and endoscopy (f) Biopsy and cytology (9) Awareness of potentials and limitations of above methods
(F) Clinical staging (a) (b) (c) (d)
Classification system ( T M N classification of malignant tumors) Diagnostic procedures Biological tumor markers Prognostic factors
(G) Management
(a) (b) (c) (d) (e) (f) (8) (h) (i) (j)
Principles of surgery, radiotherapy, & medical cancer treatment Concepts of cure (end points) Concepts of palliation Management of pain Quality of life Hospital care vs. home care Terminal care Communication with patients, relatives, other health professionals Role of doctors in public education Community assets (societies, support groups, etc.)
(H) Psychology (a) Patient and family counseling (b) Psychosocial support
35 1
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Ron MacCormick et al.
(I) Clinical trials (a) Methodology (b) Ethics (c) Limitations
(J) Practical training (a) Especially in areas of practical skills and early diagnosis
(K) Practical diagnosis (a) (b) (c) (d) (e)
Direct exposure to patients & taking a cancer history Methods of early diagnosis & palpation of lumps Oral, vaginal & rectal examinations Cervical smear Cytology
(L) Multi-disciplinary management of the main tumor types
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
(a) Common cancers, especially those that are curable
Appendix 2: Intern survey and results Twenty-four interns responded to this survey out of a possible 32 surveys sent to the various Dalhousie graduates who were interning in the meter0 area this summer. 1) Regarding your four years of undergraduate training at Dalhousie, do you agree with any of the following statements about the Oncology curriculum: (a) (b) (c) (d) (e) (f)
Insufficient total time devoted to oncology Duplication of material in different courses Inappropriate emphasis of material Outdated material taught Material disorganized Material spread out through too many different courses
2) Are there adequate opportunities to pursue electives in the jield of oncology?
Y 44% ( 1 1 ) Y 46% (12) Y 40% (10) Y 37% (9) Y 80% (19) Y 80%(19)
N 56% (14) N 54% (13) N 60%(15) N 63% (15) N 20% (6) N 2 0 % (6)
Y 65% (15)
N 35% (8)
Do you plan to specialize in any aspects of oncology? Definitely 0% Strong possibility 0% Slight possibility 40% (10)
N o 60% (15)
3) Where do you feel you have gained most of your knowledge and experience in the jield of oncology (i.e. which courses or rotations)? In clerkship 4 Gynecology 8 D&B 2 Surgery 10 Pathology 8 Urology 4 EENT 1 Medicine 5 Respirology 2 Electives 5 4) After four years of medicine, how prepared for the management of a cancer patient do you feel? (rate your preparedness on a scale of I to 4) 4 =completely prepared, 1 =insufficiently prepared 40% 3:47% ( 1 1 ) 2.5:13% (3) 2:40% (9) 1:0%
5) To what extent wereyou exposed to thefollowing topics duringyourfouryears at medical school at Dalhousie? 3 =covered well, 2 =covered minimally, 1 =not covered Biology of cancers in terms of cell kinetics, oncogenes, and growth factors 2.512% (3) 2:24% (6) 1:0% 3:64% (16) The causes of cancer (carcinogens, genetics, environment) 2.5:8% (2) 2:12% (3) 1:0% 3:80% (20) Infiltration and metastases 3:64% (16) 2:28% (7) 1:8% (2) Epidemiology of cancer 3:84% (21) 2 5 8 % (2) 2:0% 1:8%(2)
Med Teach Downloaded from informahealthcare.com by UB Kiel on 10/27/14 For personal use only.
Oncology at Dalhousie medical school
353
Cancer screening 3 5 2 % (13) 2:44% (11) 1:4% (1) Methods of imaging (radiology, isotopes, ultrasound, MRI) and endoscopy 2.5: 13% (3) 2:74% (17) 1:0% 3:13% ( 3 ) Classification of tumors (TMN system) 3:50% (12) 2:50% (12) 1:0% Principles of surgery, radiotherapy, and medical cancer treatment 3:33% (8) 2 5 8 % (2) 258% (14) 1:0% Palliative care 350% (12) 2:46% (11) 1:4% (1) Pain management 3:68% (15) 2.5:14% (3) 2:18% (4) 1:0% Psychosocial support for the patient and family 3:42% (10) 250% (1 2) 1:8% (2) Direct exposure to patients with cancer 3:41% (9) 2514% ( 3 ) 2:36% (8) 1:9% (2) Methods of early diagnosis 3:25% (6) 2.5:8% (2) 2:64% (14) 1:8% (2) Interactions between many disciplines in the management of a cancer patient 3:18% (4) 2.5:9% (2) 2:64% (14) 1:18% (4) 6 ) Do you have any specijic suggestions as to ways in which the oncology curriculum at Dalhousie could be
improved? 0 More emphasis on practical aspects of patient care. 0 A course in oncology would be good. Above would make an ideal course. 0 Increase time in early detection and pain management. 0 Follow 1-2 patients through a year of medical school, learning how they were diagnosed and managed. 0 Students should have more exposure to cancer patients early in their career. 0 Bring it together in a more organized fashion. 0 More appropriate lectures on chemo/radiation therapy overall for a cancer. 0 More exposure to palliative care in geriatrics. 0 More small group teaching in med IWIV. 0 Extend duration of medical school by 1 year to include several important areas that do not get curriculum time.
