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ASCO 2013 – The evolution of fellowship training: Concurrent oncology and palliative care
by Jamie Von Roenn, MD, and Charles von Gunten, MD, PhD – The call to integrate palliative care practices and principles into comprehensive cancer care, not as something that happens after treatment is over but as a standard component of optimal oncology care, is growing louder. In 2009, ASCO reviewed its accomplishments in palliative cancer care and outlined recommendations to achieve the Society’s vision of concurrent palliative and oncologic care as “usual” care by 2020.1
Dr. Jamie Von Roenn
Progress has been made by both ASCO and the oncology community as a whole. Last year, ASCO published its Provisional Clinical Opinion, “The Integration of Palliative Care into Standard Oncology,” recommending that palliative care be integrated early (at diagnosis) into the care of patients with metastatic disease and provided for any patient (curable or not) with a high symptom burden.2 This recommendation is underscored by the most recent palliative care guidelines from the National Comprehensive Cancer Network that advocate for palliative care throughout the course of the cancer experience.3
Dr. Charles von Gunten
Gaps in palliative care education
To actualize ASCO’s vision of comprehensive, integrated oncology care, changes in education and training have been initiated. For example, the Medical Oncology In-Training Examination includes questions focused on palliative cancer care. A thematic meeting focused on palliative cancer care is set to begin in 2014. International activities also reflect the Society’s growing commitment to palliative care. ASCO’s international Multidisciplinary Cancer Management Course embraces palliative care content, and a subset of the International Development and Education Award grants specifically target oncologists who are focusing on the integration of palliative care into cancer care in their countries.
In 2010, the ASCO Task Force on Palliative Care and the European Society for Medical Oncology palliative care working group submitted a revision of the palliative care content of the Global Core Curriculum in Medical Oncology to include palliative care skills as core elements of oncology training.4 ASCO has called for the integration of palliative care skills into oncology training and continuing medical education, as well as making these skills a requirement of certification. This is important because for many patients, the medical oncologist assumes responsibility for the coordination and delivery of cancer care. Yet, training of medical oncologists in symptom management, communication skills, and palliative care principles is inadequate.
A 2011 survey of randomly selected oncologists rated the quality of their medical school training in pain management as three out of 10, and for residency, five out of 10.5 Similarly, a study of oncology fellows’ training and knowledge in palliative care demonstrated training deficiencies in communication skills, symptom management, and end-of-life care.6 Fellows reported that they were more likely to receive feedback when performing bone marrow biopsies, a relatively straightforward procedure, than when engaging in end-of-life discussions (73% vs. 56%, respectively, p = 0.006), a complicated, nuanced conversation. The fellows demonstrated inadequate knowledge in basic symptom-management skills necessary to care for patients with both curable and incurable cancer. Only 31% of the fellows correctly calculated a simple opioid conversion, and less than half of the fellows chose the appropriate interval for breakthrough dosing of an opioid. Forty percent of fellows were unable to correctly identify the signs and symptoms of depression. Fewer than half of the fellows recognized the entry criteria for hospice. In spite of this lack of training, the fellows endorsed the importance of skills in palliative care. These findings underscore the need to improve the palliative care education for our future oncology workforce.
Online spaced education
With support from a National Cancer Institute grant, a new ASCO project, directed by the authors of this editorial, will develop, evaluate, and disseminate a novel, online curriculum to improve training in palliative cancer care for all oncology fellows. This internet-based education program, being built on the ASCO University® platform, is attractive because of its widespread access, potential adaptability to individual learning styles, and low cost.
Interactive electronic education offers some distinct advantages over traditional lectures or educational workshops, such as a week-long palliative care course for fellows. It allows learners more flexibility in designing their own education and can be integrated into the existing rigors of oncology training programs. Additionally, the program delivers multiple sequenced sessions to reinforce learning on a timeline that is most convenient for the learner. Well designed, internet-based, multicomponent electronic education has been shown to increase education to at least the same degree as workshop training.7
Furthermore, electronic education has been demonstrated to change physician behaviors that affect patient care, the key outcome of training.8 Interactive spaced education, the program to be used for this training, has been shown to improve learners’ knowledge acquisition and retention.9 Spaced education will be provided online via twice-weekly emails to the fellows. The emails will present clinical cases with an associated multiple choice question. The learner submits answers online and receives immediate feedback and supplemental educational material. The “take-home” educational message will be retested at a later date if the learner did not answer the question correctly. This approach to online education is based on the finding that education that is repeated over time leads to more efficient learning and higher retention than when education is presented in a single focused encounter.
A three-arm strategy will test the effectiveness of the program. The first group will complete the online education curriculum during the second half of their first year of training and the first half of their second year. The second group will complete the same online program, as well as a clinical rotation on a palliative care service during the first half of their second year.
We want to know if an oncology fellow needs to participate in a practical clinical exercise in order to learn the palliative care material. Only fellowship programs co-located in the same city as accredited palliative care programs will be assigned to this group. The third group will have delayed exposure to the training and will complete the curriculum during the last 18 months of their fellowship. This will allow an assessment of attitude and knowledge change from the education program, as measured by the palliative care component of the fellows’ in-service examination and a separate palliative care questionnaire for participating fellows. This program responds to ASCO’s 2009 commitment to develop educational programs with focused palliative care content and work toward “real world” concurrent oncology and palliative care for all patients with cancer.
Without adequate training, integrated care is only a dream. However, if this educational program leads to the expected changes in knowledge and attitudes, it can be readily integrated into all oncology training programs. With ASCO University as the program’s platform, expansion of this education initiative, nationally and internationally, is feasible and economical.
We are actively recruiting fellowship programs for participation and anticipate initiation of the training program in March 2014. Further information is available in the Trainees & Junior Faculty Member Lounge, S501, or by emailing training@asco.org.
