International Journal of

Radiation Oncology biology

physics

www.redjournal.org

Education Original Article

Radiation Oncology Medical Student Clerkship: Implementation and Evaluation of a Bi-institutional Pilot Curriculum Daniel W. Golden, MD,* Alexander Spektor, MD, PhD,y Sonali Rudra, MD,* Mark C. Ranck, MD,* Monica S. Krishnan, MD,y Rachel B. Jimenez, MD,y Akila N. Viswanathan, MD, MPH,y Matthew Koshy, MD,* Andrew R. Howard, MD,* and Steven J. Chmura, MD, PhD* *Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, Chicago, Illinois; and y Department of Radiation Oncology, Brigham and Women’s Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts Received Aug 30, 2013, and in revised form Oct 17, 2013. Accepted for publication Oct 29, 2013.

Summary The fourth-year medical student pursuing radiation oncology as a specialty completes an average of 3 radiation oncology clerkships. However, students report infrequent level-appropriate didactics. A structured didactic curriculum was developed and implemented at 2 academic medical centers in 2012. Students rated all components of the curriculum as “extremely useful.” As a result of completing the curriculum, medical students reported feeling more comfortable with their specialty decision and

Purpose: To develop and evaluate a structured didactic curriculum to complement clinical experiences during radiation oncology clerkships at 2 academic medical centers. Methods and Materials: A structured didactic curriculum was developed to teach fundamentals of radiation oncology and improve confidence in clinical competence. Curriculum lectures included: (1) an overview of radiation oncology (history, types of treatments, and basic clinic flow); (2) fundamentals of radiation biology and physics; and (3) practical aspects of radiation treatment simulation and planning. In addition, a hands-on dosimetry session taught students fundamentals of treatment planning. The curriculum was implemented at 2 academic departments in 2012. Students completed anonymous evaluations using a Likert scale to rate the usefulness of curriculum components (1 Z not at all, 5 Z extremely). Likert scores are reported as (median [interquartile range]). Results: Eighteen students completed the curriculum during their 4-week rotation (University of Chicago nZ13, Harvard Longwood Campus nZ5). All curriculum components were rated as extremely useful: introduction to radiation oncology (5 [4-5]); radiation biology and physics (5 [5-5]); practical aspects of radiation oncology (5 [4-5]); and the treatment planning session (5 [5-5]). Students rated the curriculum as “quite useful” to “extremely useful” (1) to help students understand radiation oncology as a specialty; (2) to increase student comfort with their specialty decision; and (3) to help students with their future transition to a radiation oncology residency. Conclusions: A standardized curriculum for medical students completing a 4-week radiation oncology clerkship was successfully implemented at 2 institutions. The curriculum was favorably

Reprint requests to: Daniel W. Golden, MD, Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, 5758 South Maryland Ave, Mail Code 9006, Chicago, IL 60637. Tel: (773) 702-6870; E-mail: [email protected] This project was funded in part by the 2013 Philips Healthcare/ Radiologic Society of North America Education Scholar Grant. Int J Radiation Oncol Biol Phys, Vol. 88, No. 1, pp. 45e50, 2014 0360-3016/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2013.10.041

Conflicts of interest: D.W.G. received grants from the Radiologic Society of North America during the conduct of the study. AcknowledgmentdThe authors thank Denise Hallman for her administrative support.

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better prepared to begin radiation oncology residency.

reviewed. As a result of completing the curriculum, medical students felt more comfortable with their specialty decision and better prepared to begin radiation oncology residency. Ó 2014 Elsevier Inc.

Introduction The standard curriculum for radiation oncology medical student clerkships generally consists of 4 weeks of clinical experiences supplemented by attendance at resident lectures, departmental lectures, and quality assurance rounds. In a 2011 national survey, medical students who completed radiation oncology clerkships reported presenting a departmental lecture during 87% of their rotations, yet only 35% of rotations were reported to include didactic lectures specifically for medical students (1). The assessment and development of structured didactic curricula has been reported for multiple specialties, including internal medicine (2), surgery (3-5), palliative medicine (6), dermatology (7), emergency medicine (8), and urology (9-11). Within radiation oncology, curricula have been developed for all third-year medical students at 1 institution (12), and at another institution as an optional 3-week elective for third-year medical students completing the surgery rotation (13). However, to our knowledge, there has not been a report of a structured didactic curriculum for students completing the radiation oncology clerkship as an elective. We therefore developed and implemented a structured didactic curriculum to complement the clinical experience during the medical student radiation oncology 4-week clerkship. Here we report the design of the curriculum and student evaluations of the curriculum.

Methods and Materials A curriculum for the radiation oncology clerkship was designed following Kern’s 6-step approach to medical education curriculum development as outlined in Table 1 (14). As an initial step before developing the curriculum, a targeted needs assessment was completed to characterize the medical student’s perception of the radiation oncology clerkship experience (1). Thirty-five medical students responded to an anonymous Web-based survey. The students reported completing a median of 3 radiation oncology clerkships (total Z 97) before applying for residency. When asked about the didactic experience on their clerkships, students reported that the clerkship experiences included formal case discussions in 35% (34 of 97), hands-on didactic sessions (eg, contouring) in 23% (22 of 97), and lectures specifically for medical students in 35% (34 of 97). Fifty-two percent of clerkships (50 of 97) were reported to have no formal lectures, case discussions, or hands-on didactic sessions. In the same survey, students who had completed radiation oncology clerkships were asked to rate different educational content that they would desire in an optimal radiation oncology rotation. Using a Likert scale (1 Z not at all important, 5 Z extremely important), educational activities that ranked moderately to extremely important to include in a clerkship curriculum were an opportunity to perform an unsupervised history and physical examination (4.8); an opportunity to give a formal lecture (4.2); a didactic hands-on session on radiation contouring (4.1) and planning (4.1); a formal case presentation to faculty

(3.9); and lectures on treatment planning (3.5), radiobiology (3.3), physics (3.2), and evidence-based medicine (3.2) (1). On the basis of these responses, a structured didactic pilot curriculum was designed to teach medical students the fundamentals of clinical radiation oncology. The curriculum consisted of 3 1-hour lectures on: (1) an overview of radiation oncology, including a history of the specialty, types of treatments, and basic clinic flow; (2) fundamentals of radiation biology and radiation physics; and (3) practical aspects of radiation treatment simulation and planning. Goals for lecture 1 included understanding the oncology care team, understanding basic radiation physics (ie, “What is a photon?”), learning a brief history of radiation oncology, understanding the radiation oncology clinical care path, and understanding levels of evidence when applying primary literature to radiation oncology clinical decisions. Goals for lecture 2 included understanding how different forms of radiation interact with tissue to treat cancer, understanding basic principles of fractionation, understanding how radiation is produced for external beam treatments, understanding how radiation dose is measured, and understanding basic treatment planning principles. Lecture 3 goals included understanding the simulation process, understanding patient immobilization methods, and understanding methods to reduce inter- and intrafraction motion. The lectures were designed to be delivered by a senior resident or faculty member. Ideally, 1 session was conducted per week with all students present. The lecture format was open, with students encouraged to ask questions. In addition to the 3 lectures, a 1-hour hands-on dosimetry planning session was developed to teach students the fundamentals of radiation treatment planning in an interactive manner. This session was designed to be facilitated by a senior resident, faculty member, physicist, or dosimetrist. Each student personally used a Pinnacle workstation (Philips Healthcare, Andover, MA) to plan a standardized case of a patient with a painful bony metastasis in the sixth thoracic vertebrae. The medical student was provided with a step-by-step guide to walk them through contouring of target volumes, turning on appropriate beams, and then modifying plan parameters, including beam arrangement and beam energy, to achieve an optimal plan with minimal risk of toxicity. The student repeatedly evaluated the plan’s doseevolume histogram and target coverage until the target volume (ie, the T6 lesion) was appropriately covered by the plan’s prescription dose. This component of the curriculum is available for download through MedEdPORTAL at https://www. mededportal.org/publication/9297 (15). The other curriculum

Table 1 Kern’s 6-step approach to medical education curriculum development 1. Problem identification and general needs assessment 2. Targeted needs assessment 3. Goals and objectives 4. Educational strategies 5. Implementation 6. Evaluation and feedback See Kern et al (14).

Volume 88  Number 1  2014

Fig. 1.

Bi-institutional clerkship curriculum

Student rating of the usefulness of each curriculum component. *Four students did not receive this lecture.

components (ie, lectures) are currently being prepared for submission to MedEdPORTAL.org for public dissemination. The curriculum was subsequently implemented at 2 academic teaching hospitals (University of Chicago and Harvard Longwood Campus) for students rotating during 2012. The Harvard Longwood Campus was previously using a didactic curriculum but elected to adopt this curriculum for consistency and to help develop and disseminate a formal structured curriculum. To ensure consistency of the curriculum between institutions, the lectures and planning session were standardized between the 2 departments. Because of technical issues, the Harvard Longwood Campus implemented the planning session as an interactive didactic experience, with the students working with a dosimetrist, whereas the University of Chicago provided each student with a Pinnacle planning station to complete the planning session. The plan reviewed during the session was the same at both institutions. All students completed an evaluation of the curriculum using Likert scales to rate the usefulness of curriculum components, comfort level with treatment planning, and comfort level with specialty selection (1 Z not at all, 2 Z somewhat, Table 2

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3 Z moderately, 4 Z quite, 5 Z extremely). Wilcoxon signed rank-sum was used to compare responses. Likert score responses are reported as median [interquartile range]. Two authors (D.W.G. and M.S.K.) independently reviewed the evaluations’ free responses and classified them into themes. Themes that overlapped from the 2 independent reviews were classified as “consistent” and are reported subsequently.

Results Eighteen students completed the curriculum during a 4-week rotation (University of Chicago nZ13, Harvard Longwood Campus nZ5). Student medical school tracks included 13 MD, 4 MD/PhD, and 1 other. Seven students had completed no prior rotations, 7 had completed 1 prior rotation, 3 had completed 2 prior rotations, and 1 student did not respond. Two students reported not planning to pursue radiation oncology as a specialty. Overall, the students consistently rated the content of the 3 lectures between “quite” and “extremely” important (Fig. 1). The

Themes from student evaluation subjective free responses for each component of the curriculum Curriculum component

“Introduction to Radiation Oncology” lecture

Representative free-response student feedback Positive themes Negative themes

“Radiation biology and physics” lecture

Positive themes

Negative themes “Practical aspects of treatment planning” lecture

Positive themes

Negative themes Radiation treatment planning session

Positive themes

Negative themes

                  

Provided a good overview Important for learning about general radiation oncology Most helpful when done at the beginning of the rotation Provide handouts Simplified complex concepts (eg, doseevolume histogram, depthedose curve, the 4 “Rs” of radiobiology) Useful information Difficult topics sometimes presented too quickly Provide handouts Useful learning about the simulation process Useful learning about immobilization devices Important concepts were covered Make more interactive Consider including the therapists Interactive aspect great for learning Enjoyed learning dosimetry concepts in a case-based format Favorite part of the rotation Move earlier in the rotation Give more of an introduction to the session Have more planning sessions during the rotation

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Fig. 2. Effect of didactic treatment planning session on student comfort with radiation treatment planning, comfort using a planning station, and confidence in understanding of an anteroposterior/posteroanterior (AP/PA) spine treatment plan. (*One student was not asked this question.)

median Likert score for the introductory lecture was 5 [interquartile range, 4-5], for the radiation biology and physics lecture it was 5 [5-5], and for the practical aspects of patient setup it was 5 [4-5]. Curriculum evaluation free responses for each individual curriculum component were reviewed and classified into “consistent” themes. Positive and negative themes for individual curriculum components are reported in Table 2. The planning workshop content was rated as “extremely” useful, with a median Likert score of 5 [interquartile range 5-5] (Fig. 1). After completing the planning workshop, students reported significantly improved comfort with radiation treatment planning (median pre session Likert score 2 [1-3] vs post session 3 [3-4], P

Radiation oncology medical student clerkship: implementation and evaluation of a bi-institutional pilot curriculum.

To develop and evaluate a structured didactic curriculum to complement clinical experiences during radiation oncology clerkships at 2 academic medical...
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