ORIGINAL REPORTS
Preferences and Outcomes for Chemotherapy Teaching in a Postgraduate Obstetrics and Gynecology Training Program Matthew L. Anderson, MD, PhD,* Abayomi Ogunwale, MD, MPH,* Brian A. Clark, BS,† Charlie C. Kilpatrick, MD,* and Claire M. Mach, PharmD*,† Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; and †Department of Clinical Sciences and Administration, University of Houston, Houston, Texas *
PURPOSE: To determine whether chemotherapy teaching
is a desired component of postgraduate training programs in obstetrics and gynecology and assess its effect on practicing clinicians. METHOD: After obtaining institutional review board
approval, 99 individuals who completed postgraduate training at a single academic medical center between 2005 and 2013 were invited to complete an online survey. Descriptive statistics were used to summarize responses. RESULTS: Of the 99 individuals, 68 (68%) completed the
survey. Respondents included physicians currently practicing in both academic medicine (n ¼ 36, 52.9%) and private practice (n ¼ 24, 35.2%). Most respondents (n ¼ 60, 88.2%) indicated that chemotherapy teaching was a desired feature of their training and expressed a preference for both formal didactics and direct clinical involvement (n ¼ 55, 80.2%). Benefits identified by respondents included improved insight into the management of symptoms commonly associated with chemotherapy (n ¼ 55, 82.1%) and an enhanced ability to counsel patients referred for oncology care (n ¼ 48, 70.5%). All respondents who pursued training in gynecologic oncology following residency (n ¼ 6) indicated that chemotherapy teaching favorably affected their fellowship experience. Of the 6 gynecologic oncologists, 3 (50%) who responded also indicated that chemotherapy teaching during residency improved their performance in fellowship interviews. CONCLUSION: Chemotherapy teaching was a desired feature of postgraduate training in general obstetrics and gynecology at the institution studied. Consideration should
Correspondence: Inquiries to Matthew L. Anderson, MD, PhD, Department of Obstetrics and Gynecology, Baylor College of Medicine, One Baylor Plaza, BCM610, Houston, TX 77030; fax: (713) 798-4855; E-mail: [email protected], [email protected]
936
be given to creating curricula that incorporate the principles and practice of chemotherapy and address the needs of obstetrics and gynecology trainees who intend to pursue both general and subspecialty practice. ( J Surg Ed 72:936C 2015 Association of Program Directors in Surgery. 941. J Published by Elsevier Inc. All rights reserved.) KEY WORDS: chemotherapy, teaching, residency, gyne-
cology, oncology, postgraduate medical education COMPETENCIES: Patient Care, Systems-Based Practice,
Medical Knowledge
INTRODUCTION Over the past 5 years, the organization of postgraduate medical training programs has dramatically evolved. Initially driven by limitations on work hours, changing attitudes of trainees now also require that educators carefully consider program content in addition to structure.1,2 Currently, the Accreditation Counsel for Graduate Medical Education (ACGME) broadly states that core postgraduate training in obstetrics and gynecology (OBG) should cover the prevention, diagnosis, and treatment of female reproductive tract cancers.3 More detailed requirements have been spelled out by the Council on Resident Education in Obstetrics and Gynecology (CREOG).4 The CREOG guidelines clearly state that residents should not only recognize each of the major chemotherapeutic agents used to treat gynecologic cancers but also understand their mechanisms of action and adverse effects. An important aspect of the CREOG guidelines is a requirement for postgraduate trainees to familiarize themselves with the methods and medications used to manage the side effects and complications of chemotherapy. The CREOG also recommends that trainees should understand the long-term consequences of these agents on female reproductive health. Although many
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.04.008
postgraduate training programs address these requirements using lecture-based didactics, trainees at many institutions also actively participate in clinical management of oncology patients and are able to gain practical experience with the use of chemotherapy in this manner. However, the opportunity to gain actual clinical experience with chemotherapy depends on the practice patterns of local gynecologic oncologists. Currently, there are very little objective data that can be used to determine whether or how topics related to chemotherapy should be taught to postgraduate OBG trainees or whether graduates of OBG training programs consider chemotherapy teaching desirable. We undertook the present study with the goal of assessing whether practicing obstetrician-gynecologists consider the training they received in chemotherapy to be valuable and to determine how this training affects their current clinical activities.
study instrument was deemed ready for use when each of its questions could be readily viewed from web addresses external to our institution. An invitation to participate in this study was then e-mailed to all individuals (n ¼ 99) who graduated from our postgraduate training program between 2005 and 2013. A cover letter included with this e-mail explained the nature and purpose of this study. If recipients of the e-mail were willing to participate, they were asked to complete the study questionnaire, which could be accessed at a web address provided with their invitation. We specifically selected former trainees of our institution as the study population because detailed information regarding the patterns and structure of chemotherapy training provided to them over the past decade is well known, allowing responses to be accurately interpreted and potential improvements to be identified. No more than 3 reminder e-mails were sent at weekly intervals to potential subjects over the 1-month interval during which the questionnaire was made available. Descriptive statistics were used to summarize responses.
METHODS Permission to conduct all study activities was obtained from the institutional review boardsof Baylor College of Medicine and its affiliated institutions (H-34967, approved June 27, 2014). Multiple focus groups were conducted with postgraduate trainees currently at our institution with the goal of identifying educational goals as well as perceived benefits and concerns related to the activities provided by our program to familiarize them with chemotherapy and its uses. Common themes identified by these interviews were used to assemble a study instrument to determine whether (a) chemotherapy training received as a trainee affects current clinical practice, (b) former trainees are satisfied with the chemotherapy training they received, and (c) preferred methods for learning chemotherapy-related topics could be delineated. Multiple questions were also included to assess the extent to which individual trainees were involved in chemotherapy during their training and whether their current practice requires the use of chemotherapeutic agents. Before its use, the survey instrument developed for this project was distributed to multiple educators and physician administrators involved in postgraduate medical education. Input was solicited from these thought leaders regarding potential benefits and concerns related to chemotherapy teaching during postgraduate medical education, particularly the 2-month second-year rotation and 1-month fourth-year rotation at the safety-net health system that serves as the primary platform for teaching trainees about gynecologic oncology at our institution. All feedback was incorporated into the final version of the study instrument (Appendix 1). Upon its completion, the survey was loaded onto a cloudbased platform for survey development and administration (SurveyMonkey, Palo Alto, CA). The online version of the
RESULTS Of the 99 physicians, 68 (68.7%) completed the online survey in response to our invitation. Two former trainees declined to participate, while no response was obtained from the 28 remaining individuals. Most respondents were between 31 and 35 years of age and were actively practicing obstetrics and gynecology in either an academic environment or private practice (Table). Other demographic features of study subjects are summarized in the Table. The proportion of gynecologic care provided by respondents as part of their current clinical practice varied widely (Fig. 1). Of the 68 respondents, 22 (32.4%) indicated that they either administer chemotherapy as part of their current clinical practice or provide care for women who have received chemotherapy, whereas 43 respondents (63.2%) did not. A total of 3 respondents (4.4%) declined to respond to this question. Slightly more than 75% of respondents stated that they wrote chemotherapy orders for 10 or fewer patients per week during their oncology rotations (Fig. 2). Involvement With Chemotherapy Education We found that most respondents acknowledged that they had received chemotherapy teaching (n ¼ 63, 94%) as part of their postgraduate education. Only 2 respondents (2.9%) indicated that they had not received any teaching, and 2 subjects failed to respond (2.9%). Most respondents (n ¼ 35, 51.5%) indicated that they had not received formal didactic teaching during their residency, despite the fact that formal instruction including clinical indications and uses of chemotherapy is routinely covered as part of the
Journal of Surgical Education Volume 72/Number 5 September/October 2015
937
45
n (%)
40
Characteristic Sex Male Female No response Age 26-30 31-35 36-40 41-45 46-50 Years posttraining 0-3 4-6 6-9 Practice setting Academic Private practice with residents Private practice with no residents Other Postresidency training (n ¼ 34) Reproductive endocrinology Maternal-fetal medicine Pediatric gynecology Gynecologic oncology Minimally invasive Contraception/family planning Other
10 (14.7) 57 (83.8) 1 (1.5) 6 38 16 7 1
(8.8) (55.9) (23.5) (10.3) (1.5)
% Respondents
TABLE. Demographic Characteristics of Study Respondents
35 30 25 20 15 10 5
0
34 (50) 18 (26.5) 16 (23.5) 37 5 19 7
(54.4) (1.47) (27.9) (10.3)
6 9 4 6 2 3 4
(8.8) (13.2) (5.9) (8.8) (2.9) (4.4) (5.9)
All data are number and percentage of participants with “yes” response.
postgraduate training program at our institution. A total of 28 individuals (41.2%) acknowledged that they received this type of training, while 5 respondents (7.4%) failed to answer this question. Only a minority of residents acknowledged that they had been taught information regarding mechanisms of action for chemotherapy (n ¼ 27, 40.3%). In addition, an overwhelming majority of respondents (n ¼ 60, 88.2%) reported that they had not received formal didactic instruction on how to complete chemotherapy
FIGURE 2. Estimated number of chemotherapy orders completed written per week by study respondents as part of their postgraduate residency training in gynecologic oncology.
orders, while 5 respondents (7.4%) indicated that they had received this type of instruction. A total of 4 individuals (5.9%) did not respond to this question. Because many of the trainees involved in initial smallgroup focus sessions voiced unease at participating in chemotherapy management, we wished to determine whether specific chemotherapy regimens were responsible for this concern. Most of the respondents indicated that there was no specific regimen that caused concerns during their oncology rotations (n ¼ 42, 62.7%). However, a number of respondents did identify a specific regimen that caused concern. These included the combination of etoposide, methotrexate, and dactinomycin, alternating with cisplatin and vincristine (EMACO; n ¼ 4, 5.9%). Other respondents identified cisplatin alone (n ¼ 1, 1.6%), Avastin (bevacizumab; n ¼ 1, 1.6%), carboplatin (n ¼ 1, 1.6%), and ifosfamide (n ¼ 1, 1.6%). A small subset of respondents completed this open-ended question by answering “all” (n ¼ 3, 4.4%). A total of 15 individuals (22.1%) failed to respond to this question.
30
Outcomes of Chemotherapy Training
% Respondents
25 20 15 10 5 0
FIGURE 1. Proportion of gynecology patients in the clinical practices of study respondents. 938
An overwhelming majority of respondents (n ¼ 60, 89.6%) indicated that chemotherapy training is an important aspect of postgraduate training in OBG, despite the fact that most (n ¼ 61, 91.0%) did not subsequently pursue a career as a gynecologic oncologist (Table). Only 4 individuals (5.9%) answered this question on our survey negatively, while 3 respondents (4.4%) failed to answer this question. Similar proportions of respondents believed that chemotherapy teaching is an important aspect of postgraduate training, regardless of whether they were currently practicing in academic medicine or private practice or had pursued subspecialty training (data not shown). Overall, most trainees indicated that the amount of chemotherapy training they received at our institution was either “too little” or
Journal of Surgical Education Volume 72/Number 5 September/October 2015
90
% Respondents
80
about referrals made to an oncologist; 12 individuals (17.7%) responded that it had not.
70 60 50 40 30 20 10 0
Effect on Future Gynecologic Oncologists We specifically queried graduates from our program who had pursued additional training in gynecologic oncology to determine how chemotherapy training had potentially affected their fellowship experiences. All study participants who were either enrolled in or had completed additional training in gynecologic oncology (n ¼ 6, 100%) indicated that involvement with chemotherapy during residency had improved their academic performance during fellowship; 3 respondents (50%) also indicated that the chemotherapy education they received favorably affected their fellowship interviews.
DISCUSSION FIGURE 3. Distribution of respondents according to preferred method of chemotherapy teaching.
“just right” (n ¼ 60, 88.2%); 3 respondents (4.4%) indicated that chemotherapy teaching was not needed as part of their response to this question. To decipher preferences for chemotherapy teaching, we directly queried former trainees on the methods they considered most effective for accomplishing this goal. An overwhelming majority of respondents indicated that a combination of formal didactics with direct clinical participation would be best (Fig. 3). Most respondents (n ¼ 36, 52.9%) did not feel that their involvement in chemotherapy administration in both the outpatient and the inpatient settings was necessary, stating that caring for inpatients admitted to the gynecologic oncology service would have been sufficient to meet their educational needs. In contrast, 22 individuals (32.4%) did not agree with this view. There were 10 respondents (14.7%) who did not respond to this question. Effect of Chemotherapy Training on Postresidency Clinical Practice To determine whether chemotherapy training during residency was valued by practicing obstetrician-gynecologists, we queried study participants regarding the effect of postgraduate chemotherapy training on their current clinical practice. Benefits of postgraduate chemotherapy education identified by respondents included improved insight into the management of symptoms associated with chemotherapy and the care of gynecologic oncology patients. Fifty-six (93%) of study respondents reported that their training in chemotherapy had improved their insights into the management of its side effects. Most respondents (n ¼ 49, 80.3%) indicated that chemotherapy training during residency had improved their ability to counsel patients
Despite recommendations to teach postgraduate trainees about the mechanisms of action, uses, and side effects of chemotherapy, there are currently no data to confirm that the national guidelines making these recommendations result in favorable long-term effect. There are also little or no data to identify optimal teaching methods for accomplishing this goal. Given that most obstetriciangynecologists do not ultimately focus their practice on oncology, it is possible that time dedicated to teaching chemotherapy might be better devoted to other topics.5 However, a number of observations argue against such as a conclusion. Firstly, general obstetrician-gynecologists play a critical role in evaluating adnexal masses and postmenopausal bleeding, which are issues not infrequently caused by gynecologic cancer. They are also frequently involved in the care of women being treated for breast and other nongynecologic cancers.6 Although fertility issues are a frequent source of concern for women undergoing chemotherapy, specialists focused on fertility preservation for patients with cancer may not be available in many communities. This means that women with breast cancer or other cancers frequently seek advice from their local obstetriciangynecologist to deal with treatment side effects, such as vaginal bleeding. General obstetrician-gynecologists may also be called upon to provide preconception or obstetrical care or both for women being treated for cancer. Lastly, chemotherapies, such as with methotrexate, and other types of targeted therapies are frequently used to treat ectopic pregnancy and other nonmalignant gynecologic conditions.7,8 Each of these points would suggest that exposure of postgraduate trainees to chemotherapy management would favorably affect their subsequent clinical practice, regardless of whether they ultimately choose to focus on the treatment of women diagnosed with a gynecologic cancer. One of the most important observations made by the present study is that trainees who gained experience with
Journal of Surgical Education Volume 72/Number 5 September/October 2015
939
chemotherapy at our institution highly value these experiences and report a favorably effect on their subsequent clinical practice. This opinion is shared by individuals engaged in a wide range of clinical activities in women’s health, not only those who have further subspecialized in gynecologic oncology or another subspecialty within OBG. These results underscore the value of developing curricula by which postgraduate OBG trainees can learn about chemotherapy and be actively involved in its management. A surprising aspect of the results reported here is that most former trainees from our institution reported that they had not been taught how to write chemotherapy orders. It is also surprising that only a minority of these trainees acknowledged that they had been formally taught basic information regarding mechanisms of action for chemotherapy. The principles and practice of chemotherapy are routinely covered as part of the core didactics required for all postgraduate trainees in our department. Furthermore, trainees at our institution have been historically involved quite actively in chemotherapy management, including the completion of chemotherapy order sets, to a much greater degree than that found at other institutions. Thus, the reasons why many study respondents feel that these topics were not covered by their training are not clear. Low rates of reported teaching may be because many residents miss required teaching sessions or are only poorly engaged in these sessions. Lastly, respondents may not consider the completion of a preprinted template as the same as “writing” chemotherapy orders. These issues have to be studied further in the future. This study possesses multiple strengths. As mentioned earlier, postgraduate trainees at our institution have been involved in the clinical management of chemotherapy to a much greater degree than their contemporaries in other programs are. This is because the gynecologic oncologists at our institution care for a large number of patients at a safety-net health system with limited resources. Levels of resident involvement have recently decreased dramatically, as alternate resources have been made available. However, this historical pattern means that respondents to this study are uniquely well positioned to provide feedback regarding chemotherapy training and how these efforts should be integrated into postgraduate medical education. The results of this study also provide practical feedback on how best to teach chemotherapy to current postgraduate trainees in obstetrics-gynecology and possibly other specialties. Respondents to this survey identified a combination of didactic and practical training as the most desirable approach to learning content related to chemotherapy. In the future, it is important to carefully assess the degree to which trainees in postgraduate medical education need to be directly involved in the practical aspects of chemotherapy management to gain educational benefit. On average, trainees at our institution reported preparing chemotherapy orders for 10 patients per week (Fig. 2). However, most 940
respondents indicated that involvement in chemotherapy management in both the inpatient and the outpatient settings was not necessary. Thus, it may be possible to focus the types of experiences in which residents are involved to optimize their effect. An option could be the development of a hybrid model that includes both face-toface instruction and web-based learning activities developed physicians and pharmacists. Similar models for collaborative teaching have been well received by residents in other programs.9 This study is also characterized by a number of limitations. Perhaps most significant is that all respondents trained at a single institution. In addition, more than half of the respondents had engaged in subspecialty fellowship training, a level significantly higher than many other institutions. Lastly, the retrospective nature of this study also means that its results are vulnerable to well-recognized confounding features such as recall and self-report biases. For example, the fact that residents who trained at our institution were likely aware that our program required an exceptional level of participation in chemotherapy-related activities before their match. This means that many of the individuals who ultimately trained at our institution may have been predisposed to find these activities favorable. Such a bias could be reflected in the fact that our department has placed a larger number of graduates in gynecologic oncology fellowships than many others did. For all of these reasons, it is important to validate the observations made here across a diverse cross section of postgraduate OBG training programs. It will also be interesting to test our hypotheses in other graduates of other medical and surgical specialties requiring the use of chemotherapeutic agents.
CONCLUSION Results of the present study clearly confirm the value of chemotherapy teaching in postgraduate OBG training programs. As postgraduate training programs have come under increased pressure, it is logical to anticipate that their content and emphasis should be ultimately driven by evidence-based recommendations. Hopefully, the initial work presented here underscores the need to include chemotherapy teaching as part of training curricula. Future work should focus not only on confirming the observations reported here but also in determining how best to accomplish training objectives and whether similar benefits might be observed in postgraduate training programs for other medical specialties.
REFERENCES 1. Antiel RM, Thompson SM, Hafferty FW, et al. Duty
hour recommendations and implications for meeting the
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ACGME core competencies: views of residency directors. Mayo Clin Proc. 2011;86(3):185-191. 2. Nevin CR, Cherrington A, Roy B, et al. A qualitative
assessment of internal medicine resident perceptions of graduate medical education following implementation of the 2011 ACGME duty hour standards. BMC Med Educ. 2014;14:84. 3. Accreditation Council for Graduate Medical Education,
Chicago, IL. ACGME program requirements for graduate medical education in obstetrics and gynecology. Available at: 〈https://www.acgme.org/acgmeweb/tabid/ 138/ProgramandInstitutionalAccreditation/SurgicalSpe cialties/ObstetricsandGynecology.aspx〉; Accessed 10.12.14. 4. American College of Obstetrics & Gynecology, Washington,
D.C. CREOG educational objectives: a core curriculum in obstetrics and gynecology, 10th ed. Available at: 〈http://www.acog.org/About-ACOG/ACOG-Depart ments/CREOG/CREOG-Search/CREOG-Educationa l-Objectives〉; 2014 Accessed 10.12.14.
5. Plotti F, Capriglione S, Miranda A, et al. The impact of
gynecologic oncology training in the management of cancer patients: is it really necessary? A prospective cohort study Eur J Obstet Gynecol Reprod Biol. 2014;184C:19-23. 6. Lambertini M, Ginsburg ES, Partridge AH. Update on
fertility preservation in young women undergoing breast cancer and ovarian cancer therapy. Curr Opin Obstet Gynecol. 2014;27(1):98-107. 7. Tong S, Skubisz MM, Horne AW. Molecular diagnos-
tics and therapeutics for ectopic pregnancy. Mol Hum Reprod. 2015;21(2):126-135. 8. Hiersch L, Krissi H, Ashwal E, From A, Wiznitzer A,
Peled Y. Effectiveness of medical treatment with methotrexate for interstitial pregnancy. Aust N Z J Obstet Gynaecol. 2014;54(6):576-580. 9. Bordman R, Bajcar J, Kennie N, Fernandes L, Iglar K.
Curriculum to enhance pharmacotherapeutic knowledge in family medicine: interprofessional coteaching and web-based learning. Can Fam Physician. 2013;59(11):e493-e498.
SUPPLEMENTARY MATERIALS Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2015.04.008.
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Preferences and Outcomes for Chemotherapy Teaching in a Postgraduate Obstetrics and Gynecology Training Program Matthew L. Anderson, MD, PhD,* Abayomi Ogunwale, MD, MPH,* Brian A. Clark, BS,† Charlie C. Kilpatrick, MD,* and Claire M. Mach, PharmD*,† Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; and †Department of Clinical Sciences and Administration, University of Houston, Houston, Texas *
PURPOSE: To determine whether chemotherapy teaching
is a desired component of postgraduate training programs in obstetrics and gynecology and assess its effect on practicing clinicians. METHOD: After obtaining institutional review board
approval, 99 individuals who completed postgraduate training at a single academic medical center between 2005 and 2013 were invited to complete an online survey. Descriptive statistics were used to summarize responses. RESULTS: Of the 99 individuals, 68 (68%) completed the
survey. Respondents included physicians currently practicing in both academic medicine (n ¼ 36, 52.9%) and private practice (n ¼ 24, 35.2%). Most respondents (n ¼ 60, 88.2%) indicated that chemotherapy teaching was a desired feature of their training and expressed a preference for both formal didactics and direct clinical involvement (n ¼ 55, 80.2%). Benefits identified by respondents included improved insight into the management of symptoms commonly associated with chemotherapy (n ¼ 55, 82.1%) and an enhanced ability to counsel patients referred for oncology care (n ¼ 48, 70.5%). All respondents who pursued training in gynecologic oncology following residency (n ¼ 6) indicated that chemotherapy teaching favorably affected their fellowship experience. Of the 6 gynecologic oncologists, 3 (50%) who responded also indicated that chemotherapy teaching during residency improved their performance in fellowship interviews. CONCLUSION: Chemotherapy teaching was a desired feature of postgraduate training in general obstetrics and gynecology at the institution studied. Consideration should
Correspondence: Inquiries to Matthew L. Anderson, MD, PhD, Department of Obstetrics and Gynecology, Baylor College of Medicine, One Baylor Plaza, BCM610, Houston, TX 77030; fax: (713) 798-4855; E-mail: [email protected], [email protected]
936
be given to creating curricula that incorporate the principles and practice of chemotherapy and address the needs of obstetrics and gynecology trainees who intend to pursue both general and subspecialty practice. ( J Surg Ed 72:936C 2015 Association of Program Directors in Surgery. 941. J Published by Elsevier Inc. All rights reserved.) KEY WORDS: chemotherapy, teaching, residency, gyne-
cology, oncology, postgraduate medical education COMPETENCIES: Patient Care, Systems-Based Practice,
Medical Knowledge
INTRODUCTION Over the past 5 years, the organization of postgraduate medical training programs has dramatically evolved. Initially driven by limitations on work hours, changing attitudes of trainees now also require that educators carefully consider program content in addition to structure.1,2 Currently, the Accreditation Counsel for Graduate Medical Education (ACGME) broadly states that core postgraduate training in obstetrics and gynecology (OBG) should cover the prevention, diagnosis, and treatment of female reproductive tract cancers.3 More detailed requirements have been spelled out by the Council on Resident Education in Obstetrics and Gynecology (CREOG).4 The CREOG guidelines clearly state that residents should not only recognize each of the major chemotherapeutic agents used to treat gynecologic cancers but also understand their mechanisms of action and adverse effects. An important aspect of the CREOG guidelines is a requirement for postgraduate trainees to familiarize themselves with the methods and medications used to manage the side effects and complications of chemotherapy. The CREOG also recommends that trainees should understand the long-term consequences of these agents on female reproductive health. Although many
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.04.008
postgraduate training programs address these requirements using lecture-based didactics, trainees at many institutions also actively participate in clinical management of oncology patients and are able to gain practical experience with the use of chemotherapy in this manner. However, the opportunity to gain actual clinical experience with chemotherapy depends on the practice patterns of local gynecologic oncologists. Currently, there are very little objective data that can be used to determine whether or how topics related to chemotherapy should be taught to postgraduate OBG trainees or whether graduates of OBG training programs consider chemotherapy teaching desirable. We undertook the present study with the goal of assessing whether practicing obstetrician-gynecologists consider the training they received in chemotherapy to be valuable and to determine how this training affects their current clinical activities.
study instrument was deemed ready for use when each of its questions could be readily viewed from web addresses external to our institution. An invitation to participate in this study was then e-mailed to all individuals (n ¼ 99) who graduated from our postgraduate training program between 2005 and 2013. A cover letter included with this e-mail explained the nature and purpose of this study. If recipients of the e-mail were willing to participate, they were asked to complete the study questionnaire, which could be accessed at a web address provided with their invitation. We specifically selected former trainees of our institution as the study population because detailed information regarding the patterns and structure of chemotherapy training provided to them over the past decade is well known, allowing responses to be accurately interpreted and potential improvements to be identified. No more than 3 reminder e-mails were sent at weekly intervals to potential subjects over the 1-month interval during which the questionnaire was made available. Descriptive statistics were used to summarize responses.
METHODS Permission to conduct all study activities was obtained from the institutional review boardsof Baylor College of Medicine and its affiliated institutions (H-34967, approved June 27, 2014). Multiple focus groups were conducted with postgraduate trainees currently at our institution with the goal of identifying educational goals as well as perceived benefits and concerns related to the activities provided by our program to familiarize them with chemotherapy and its uses. Common themes identified by these interviews were used to assemble a study instrument to determine whether (a) chemotherapy training received as a trainee affects current clinical practice, (b) former trainees are satisfied with the chemotherapy training they received, and (c) preferred methods for learning chemotherapy-related topics could be delineated. Multiple questions were also included to assess the extent to which individual trainees were involved in chemotherapy during their training and whether their current practice requires the use of chemotherapeutic agents. Before its use, the survey instrument developed for this project was distributed to multiple educators and physician administrators involved in postgraduate medical education. Input was solicited from these thought leaders regarding potential benefits and concerns related to chemotherapy teaching during postgraduate medical education, particularly the 2-month second-year rotation and 1-month fourth-year rotation at the safety-net health system that serves as the primary platform for teaching trainees about gynecologic oncology at our institution. All feedback was incorporated into the final version of the study instrument (Appendix 1). Upon its completion, the survey was loaded onto a cloudbased platform for survey development and administration (SurveyMonkey, Palo Alto, CA). The online version of the
RESULTS Of the 99 physicians, 68 (68.7%) completed the online survey in response to our invitation. Two former trainees declined to participate, while no response was obtained from the 28 remaining individuals. Most respondents were between 31 and 35 years of age and were actively practicing obstetrics and gynecology in either an academic environment or private practice (Table). Other demographic features of study subjects are summarized in the Table. The proportion of gynecologic care provided by respondents as part of their current clinical practice varied widely (Fig. 1). Of the 68 respondents, 22 (32.4%) indicated that they either administer chemotherapy as part of their current clinical practice or provide care for women who have received chemotherapy, whereas 43 respondents (63.2%) did not. A total of 3 respondents (4.4%) declined to respond to this question. Slightly more than 75% of respondents stated that they wrote chemotherapy orders for 10 or fewer patients per week during their oncology rotations (Fig. 2). Involvement With Chemotherapy Education We found that most respondents acknowledged that they had received chemotherapy teaching (n ¼ 63, 94%) as part of their postgraduate education. Only 2 respondents (2.9%) indicated that they had not received any teaching, and 2 subjects failed to respond (2.9%). Most respondents (n ¼ 35, 51.5%) indicated that they had not received formal didactic teaching during their residency, despite the fact that formal instruction including clinical indications and uses of chemotherapy is routinely covered as part of the
Journal of Surgical Education Volume 72/Number 5 September/October 2015
937
45
n (%)
40
Characteristic Sex Male Female No response Age 26-30 31-35 36-40 41-45 46-50 Years posttraining 0-3 4-6 6-9 Practice setting Academic Private practice with residents Private practice with no residents Other Postresidency training (n ¼ 34) Reproductive endocrinology Maternal-fetal medicine Pediatric gynecology Gynecologic oncology Minimally invasive Contraception/family planning Other
10 (14.7) 57 (83.8) 1 (1.5) 6 38 16 7 1
(8.8) (55.9) (23.5) (10.3) (1.5)
% Respondents
TABLE. Demographic Characteristics of Study Respondents
35 30 25 20 15 10 5
0
34 (50) 18 (26.5) 16 (23.5) 37 5 19 7
(54.4) (1.47) (27.9) (10.3)
6 9 4 6 2 3 4
(8.8) (13.2) (5.9) (8.8) (2.9) (4.4) (5.9)
All data are number and percentage of participants with “yes” response.
postgraduate training program at our institution. A total of 28 individuals (41.2%) acknowledged that they received this type of training, while 5 respondents (7.4%) failed to answer this question. Only a minority of residents acknowledged that they had been taught information regarding mechanisms of action for chemotherapy (n ¼ 27, 40.3%). In addition, an overwhelming majority of respondents (n ¼ 60, 88.2%) reported that they had not received formal didactic instruction on how to complete chemotherapy
FIGURE 2. Estimated number of chemotherapy orders completed written per week by study respondents as part of their postgraduate residency training in gynecologic oncology.
orders, while 5 respondents (7.4%) indicated that they had received this type of instruction. A total of 4 individuals (5.9%) did not respond to this question. Because many of the trainees involved in initial smallgroup focus sessions voiced unease at participating in chemotherapy management, we wished to determine whether specific chemotherapy regimens were responsible for this concern. Most of the respondents indicated that there was no specific regimen that caused concerns during their oncology rotations (n ¼ 42, 62.7%). However, a number of respondents did identify a specific regimen that caused concern. These included the combination of etoposide, methotrexate, and dactinomycin, alternating with cisplatin and vincristine (EMACO; n ¼ 4, 5.9%). Other respondents identified cisplatin alone (n ¼ 1, 1.6%), Avastin (bevacizumab; n ¼ 1, 1.6%), carboplatin (n ¼ 1, 1.6%), and ifosfamide (n ¼ 1, 1.6%). A small subset of respondents completed this open-ended question by answering “all” (n ¼ 3, 4.4%). A total of 15 individuals (22.1%) failed to respond to this question.
30
Outcomes of Chemotherapy Training
% Respondents
25 20 15 10 5 0
FIGURE 1. Proportion of gynecology patients in the clinical practices of study respondents. 938
An overwhelming majority of respondents (n ¼ 60, 89.6%) indicated that chemotherapy training is an important aspect of postgraduate training in OBG, despite the fact that most (n ¼ 61, 91.0%) did not subsequently pursue a career as a gynecologic oncologist (Table). Only 4 individuals (5.9%) answered this question on our survey negatively, while 3 respondents (4.4%) failed to answer this question. Similar proportions of respondents believed that chemotherapy teaching is an important aspect of postgraduate training, regardless of whether they were currently practicing in academic medicine or private practice or had pursued subspecialty training (data not shown). Overall, most trainees indicated that the amount of chemotherapy training they received at our institution was either “too little” or
Journal of Surgical Education Volume 72/Number 5 September/October 2015
90
% Respondents
80
about referrals made to an oncologist; 12 individuals (17.7%) responded that it had not.
70 60 50 40 30 20 10 0
Effect on Future Gynecologic Oncologists We specifically queried graduates from our program who had pursued additional training in gynecologic oncology to determine how chemotherapy training had potentially affected their fellowship experiences. All study participants who were either enrolled in or had completed additional training in gynecologic oncology (n ¼ 6, 100%) indicated that involvement with chemotherapy during residency had improved their academic performance during fellowship; 3 respondents (50%) also indicated that the chemotherapy education they received favorably affected their fellowship interviews.
DISCUSSION FIGURE 3. Distribution of respondents according to preferred method of chemotherapy teaching.
“just right” (n ¼ 60, 88.2%); 3 respondents (4.4%) indicated that chemotherapy teaching was not needed as part of their response to this question. To decipher preferences for chemotherapy teaching, we directly queried former trainees on the methods they considered most effective for accomplishing this goal. An overwhelming majority of respondents indicated that a combination of formal didactics with direct clinical participation would be best (Fig. 3). Most respondents (n ¼ 36, 52.9%) did not feel that their involvement in chemotherapy administration in both the outpatient and the inpatient settings was necessary, stating that caring for inpatients admitted to the gynecologic oncology service would have been sufficient to meet their educational needs. In contrast, 22 individuals (32.4%) did not agree with this view. There were 10 respondents (14.7%) who did not respond to this question. Effect of Chemotherapy Training on Postresidency Clinical Practice To determine whether chemotherapy training during residency was valued by practicing obstetrician-gynecologists, we queried study participants regarding the effect of postgraduate chemotherapy training on their current clinical practice. Benefits of postgraduate chemotherapy education identified by respondents included improved insight into the management of symptoms associated with chemotherapy and the care of gynecologic oncology patients. Fifty-six (93%) of study respondents reported that their training in chemotherapy had improved their insights into the management of its side effects. Most respondents (n ¼ 49, 80.3%) indicated that chemotherapy training during residency had improved their ability to counsel patients
Despite recommendations to teach postgraduate trainees about the mechanisms of action, uses, and side effects of chemotherapy, there are currently no data to confirm that the national guidelines making these recommendations result in favorable long-term effect. There are also little or no data to identify optimal teaching methods for accomplishing this goal. Given that most obstetriciangynecologists do not ultimately focus their practice on oncology, it is possible that time dedicated to teaching chemotherapy might be better devoted to other topics.5 However, a number of observations argue against such as a conclusion. Firstly, general obstetrician-gynecologists play a critical role in evaluating adnexal masses and postmenopausal bleeding, which are issues not infrequently caused by gynecologic cancer. They are also frequently involved in the care of women being treated for breast and other nongynecologic cancers.6 Although fertility issues are a frequent source of concern for women undergoing chemotherapy, specialists focused on fertility preservation for patients with cancer may not be available in many communities. This means that women with breast cancer or other cancers frequently seek advice from their local obstetriciangynecologist to deal with treatment side effects, such as vaginal bleeding. General obstetrician-gynecologists may also be called upon to provide preconception or obstetrical care or both for women being treated for cancer. Lastly, chemotherapies, such as with methotrexate, and other types of targeted therapies are frequently used to treat ectopic pregnancy and other nonmalignant gynecologic conditions.7,8 Each of these points would suggest that exposure of postgraduate trainees to chemotherapy management would favorably affect their subsequent clinical practice, regardless of whether they ultimately choose to focus on the treatment of women diagnosed with a gynecologic cancer. One of the most important observations made by the present study is that trainees who gained experience with
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chemotherapy at our institution highly value these experiences and report a favorably effect on their subsequent clinical practice. This opinion is shared by individuals engaged in a wide range of clinical activities in women’s health, not only those who have further subspecialized in gynecologic oncology or another subspecialty within OBG. These results underscore the value of developing curricula by which postgraduate OBG trainees can learn about chemotherapy and be actively involved in its management. A surprising aspect of the results reported here is that most former trainees from our institution reported that they had not been taught how to write chemotherapy orders. It is also surprising that only a minority of these trainees acknowledged that they had been formally taught basic information regarding mechanisms of action for chemotherapy. The principles and practice of chemotherapy are routinely covered as part of the core didactics required for all postgraduate trainees in our department. Furthermore, trainees at our institution have been historically involved quite actively in chemotherapy management, including the completion of chemotherapy order sets, to a much greater degree than that found at other institutions. Thus, the reasons why many study respondents feel that these topics were not covered by their training are not clear. Low rates of reported teaching may be because many residents miss required teaching sessions or are only poorly engaged in these sessions. Lastly, respondents may not consider the completion of a preprinted template as the same as “writing” chemotherapy orders. These issues have to be studied further in the future. This study possesses multiple strengths. As mentioned earlier, postgraduate trainees at our institution have been involved in the clinical management of chemotherapy to a much greater degree than their contemporaries in other programs are. This is because the gynecologic oncologists at our institution care for a large number of patients at a safety-net health system with limited resources. Levels of resident involvement have recently decreased dramatically, as alternate resources have been made available. However, this historical pattern means that respondents to this study are uniquely well positioned to provide feedback regarding chemotherapy training and how these efforts should be integrated into postgraduate medical education. The results of this study also provide practical feedback on how best to teach chemotherapy to current postgraduate trainees in obstetrics-gynecology and possibly other specialties. Respondents to this survey identified a combination of didactic and practical training as the most desirable approach to learning content related to chemotherapy. In the future, it is important to carefully assess the degree to which trainees in postgraduate medical education need to be directly involved in the practical aspects of chemotherapy management to gain educational benefit. On average, trainees at our institution reported preparing chemotherapy orders for 10 patients per week (Fig. 2). However, most 940
respondents indicated that involvement in chemotherapy management in both the inpatient and the outpatient settings was not necessary. Thus, it may be possible to focus the types of experiences in which residents are involved to optimize their effect. An option could be the development of a hybrid model that includes both face-toface instruction and web-based learning activities developed physicians and pharmacists. Similar models for collaborative teaching have been well received by residents in other programs.9 This study is also characterized by a number of limitations. Perhaps most significant is that all respondents trained at a single institution. In addition, more than half of the respondents had engaged in subspecialty fellowship training, a level significantly higher than many other institutions. Lastly, the retrospective nature of this study also means that its results are vulnerable to well-recognized confounding features such as recall and self-report biases. For example, the fact that residents who trained at our institution were likely aware that our program required an exceptional level of participation in chemotherapy-related activities before their match. This means that many of the individuals who ultimately trained at our institution may have been predisposed to find these activities favorable. Such a bias could be reflected in the fact that our department has placed a larger number of graduates in gynecologic oncology fellowships than many others did. For all of these reasons, it is important to validate the observations made here across a diverse cross section of postgraduate OBG training programs. It will also be interesting to test our hypotheses in other graduates of other medical and surgical specialties requiring the use of chemotherapeutic agents.
CONCLUSION Results of the present study clearly confirm the value of chemotherapy teaching in postgraduate OBG training programs. As postgraduate training programs have come under increased pressure, it is logical to anticipate that their content and emphasis should be ultimately driven by evidence-based recommendations. Hopefully, the initial work presented here underscores the need to include chemotherapy teaching as part of training curricula. Future work should focus not only on confirming the observations reported here but also in determining how best to accomplish training objectives and whether similar benefits might be observed in postgraduate training programs for other medical specialties.
REFERENCES 1. Antiel RM, Thompson SM, Hafferty FW, et al. Duty
hour recommendations and implications for meeting the
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ACGME core competencies: views of residency directors. Mayo Clin Proc. 2011;86(3):185-191. 2. Nevin CR, Cherrington A, Roy B, et al. A qualitative
assessment of internal medicine resident perceptions of graduate medical education following implementation of the 2011 ACGME duty hour standards. BMC Med Educ. 2014;14:84. 3. Accreditation Council for Graduate Medical Education,
Chicago, IL. ACGME program requirements for graduate medical education in obstetrics and gynecology. Available at: 〈https://www.acgme.org/acgmeweb/tabid/ 138/ProgramandInstitutionalAccreditation/SurgicalSpe cialties/ObstetricsandGynecology.aspx〉; Accessed 10.12.14. 4. American College of Obstetrics & Gynecology, Washington,
D.C. CREOG educational objectives: a core curriculum in obstetrics and gynecology, 10th ed. Available at: 〈http://www.acog.org/About-ACOG/ACOG-Depart ments/CREOG/CREOG-Search/CREOG-Educationa l-Objectives〉; 2014 Accessed 10.12.14.
5. Plotti F, Capriglione S, Miranda A, et al. The impact of
gynecologic oncology training in the management of cancer patients: is it really necessary? A prospective cohort study Eur J Obstet Gynecol Reprod Biol. 2014;184C:19-23. 6. Lambertini M, Ginsburg ES, Partridge AH. Update on
fertility preservation in young women undergoing breast cancer and ovarian cancer therapy. Curr Opin Obstet Gynecol. 2014;27(1):98-107. 7. Tong S, Skubisz MM, Horne AW. Molecular diagnos-
tics and therapeutics for ectopic pregnancy. Mol Hum Reprod. 2015;21(2):126-135. 8. Hiersch L, Krissi H, Ashwal E, From A, Wiznitzer A,
Peled Y. Effectiveness of medical treatment with methotrexate for interstitial pregnancy. Aust N Z J Obstet Gynaecol. 2014;54(6):576-580. 9. Bordman R, Bajcar J, Kennie N, Fernandes L, Iglar K.
Curriculum to enhance pharmacotherapeutic knowledge in family medicine: interprofessional coteaching and web-based learning. Can Fam Physician. 2013;59(11):e493-e498.
SUPPLEMENTARY MATERIALS Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2015.04.008.
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