In this study, we introduced a new instrument designed for the evaluation of a Cancer As Chronic Disease curriculum and determined its psychometric properties. A panel of experts determined the crucial skills and knowledge needed for survivorship care and subsequently drafted questions related to one of seven competency domains, resulting into an instrument with inherent content validity. In addition, we found evidence for its discriminant validity. Specifically, oncology fellows, who presumably had better knowledge of cancer survivorship, outperformed medical students albeit at an unsatisfactory level. The internal consistency of our instrument was modest (0.67) but adequate for program evaluation.
Senior medical students in three institutions demonstrated limited knowledge about cancer as a chronic disease. On average, students answered about half of the questions correctly while oncology fellows performed only slightly better. In fact, we found a negative score for Competency 7 suggesting that students may have misconceptions, and not just lack of knowledge, about the consequences of cancer treatment on growth, osteoporosis, learning, sexual function, and fertility. Furthermore, students were exposed to cancer survivors frequently in medical school (with the exception of childhood cancer survivors). Nonetheless, about half of the student never received direct instruction or practiced critical components of survivorship care. In addition, and perhaps consequently, students reported low confidence in all cancer survivorship-related patient care activities, such as giving bad news, tailoring pain medication, and working with a specialty team. The latter is particularly disconcerting given the multidisciplinary nature of survivorship care.
Our study has several limitations. First, a relatively low number of oncology fellows participated (compared to the number of medical students). Thus, they may not have represented fellows nationally. Furthermore, our study relied on students’ self-reported experience and competence in survivorship care. Previous studies (e.g.,xii
) have shown that self-reported competence may lack validity. Finally, the level of reliability of our knowledge test precludes its use for assessment of individual students. Future studies involving larger samples could conduct item-item correlations and Exploratory Factor Analysis to identify items that do not fit and may lower the internal consistency. These items could be replaced or removed all together to improve the reliability of the knowledge test.
Nonetheless, our assessment instrument could be used to evaluate educational interventions designed to improve knowledge of long-term effects of cancer or to conduct a needs assessment as described in this study. Our short assessment tool could function as a benchmark against which subsequent curricular innovations can be evaluated. In this survey, senior students who had not been exposed to a survivorship curriculum, had limited knowledge about cancer as a chronic disease, experienced inadequate training, and reported low confidence levels in related clinical skills, underscoring the need for a dedicated survivorship curriculum. Since then, the three participating institutions have been implementing a comprehensive survivorship curriculum using the survey instrument to monitor its effect. Evidence was recently presented that the new curriculum improved knowledge and self-rated competency.xiii
We also found that oncology fellows showed a surprising lack of knowledge in this domain. As Ferrel and Winn8
pointed out, improvement of both undergraduate and postgraduate training in survivorship care is urgently warranted. Additional efforts are needed to ensure that knowledge and experience gained during undergraduate training transfer into subsequent phases of the educational continuum. A thorough understanding of the special needs of cancer survivors, including psychosocial functioning and long-term effects of treatment, is of paramount concern for both primary care and specialty physicians who will be providing quality care for this special populationxiv