During the last 5 years (from 2003 through 2008), the David Geffen School of Medicine at UCLA, the University of California, San Francisco School of Medicine, and the Charles Drew University of Medicine and Science (CDU) have collaboratively developed a 4-year, integrated curriculum in cancer survivorship with support of an NCI R25 grant. Development of this curriculum occurred in several phases: (1) identification of curriculum objectives; (2) development of educational interventions and integration into the existing curriculum; (3) evaluation and dissemination. The curriculum focused on common cancers with increasing survival rates: breast, colorectal, prostate, and gynecological cancers along with childhood cancers such as leukemia.
- Identification of curriculum objectives
A 15-member multidisciplinary expert consensus panel with representation from the three participating institutions was charged with developing a set of curriculum objectives for the care of patients with cancer as a chronic disease10
. Faculty members from various oncology specialties, primary care, and curriculum design specialists met at each of the institutions and created comprehensive lists of knowledge, attitudes, and skills related to survivorship care that medical students should demonstrate upon graduation. Next, using a modified Delphi process, panel members prioritized all items on the collated list, resulting in a final set of 17 objectives. Knowledge objectives pertained to epidemiology of survival, survival rates, psychosocial effects of cancer, and long-term effects of treatment. Skill objectives included, but were not limited to, provide recommendations for secondary prevention of cancer, prescribe appropriate pain medication, give bad news about a second malignancy, and locate current cancer information. The complete list of curriculum objectives has appeared in the Institute of Medicine report, From Cancer Patient to Cancer Survivors: Lost in Translation3
- Development and implementation of educational interventions
Curriculum objectives guided the development of educational interventions addressing specific cancers12
. A modular approach was taken as opposed to developing a new course or clerkship. That is, smaller stand-alone units that supported a limited number of objectives were created to allow integration into existing courses and clerkships. The resulting set of approximately 30 educational modules used a variety of educational strategies (see Table for a complete overview). The following is a representative sample:
- The case of Mrs. Hernandez: a video problem-based learning (PBL) case
Survivorship Curricular Materials Developed Under NCI 096975
This video-based PBL case features Mrs. Hernandez, a 56-year-old immigrant from Mexico, who presents to an urgent care physician with chest pain and cough. She is initially diagnosed with pneumonia. Her symptoms progress, and she is subsequently diagnosed with stage IIIA adenocarcinoma of the lung, which is treated with chemotherapy and radiotherapy. The case ends with a 6-month follow-up visit when the patient is in remission, and the physician must discuss her concerns about recurrence of her cancer and her health beliefs. Students learn to describe the pathophysiology of lung cancer, the relationship between staging and prognosis, and the factors affecting the patient’s quality of life after treatment.
- Surviving endometrial cancer: a computer-based self-study module
In this module, students encounter a 64-year-old woman who visits her primary care physician after being treated for Stage 2A endometrial cancer. Over the subsequent 20 months, she returns to the physician several times for a variety of complaints, including hair loss, swollen feet, weight loss, and concerns about recurrence of the cancer. At her 1-year checkup with the oncologist, she is diagnosed with a para-aortic lymph node indicative of a localized relapse. With each visit, the student is required to make diagnostic, treatment, and counseling decisions.
- The human side of survivorship: panel and theater presentation of cancer survivors
First-year medical students have an opportunity to see the human side of survivorship issues through a 90-min panel presentation. The panel occurs during a week in which the students analyze skin biopsies from patients with malignant melanoma. Three or four cancer survivors tell their stories, starting with how they were diagnosed and treated. They then discuss the impact of cancer and treatment on their relationships, jobs, and self-perception. They describe how they coped with interacting with multidisciplinary teams, their use of complementary or alternative medicine, and any insurance issues they encountered. Students have reviewed this panel presentation very positively and are grateful for this glimpse into the cancer experience. In addition, students have a chance to see a one-woman show on the experience of being a cancer survivor (Jonna’s Body13
). Dramatic story telling and humor create emotional links for students to the survivorship experience.
- Cancer survivorship write-up exercise
In this exercise, students identify a cancer survivor among the patients for whom they are caring during their inpatient internal medicine clerkship. The patient may or may not have been hospitalized because of a cancer-related problem. Guided by a template, they conduct and then write up a detailed cancer history of the patient, including details of cancer treatment and follow-up. In addition to the usual history and physical examination findings, students are prompted to address quality of life issues, pain control, advance directives, and secondary screening. This write-up exercise is designed to prompt students to identify cancer survivors during their clerkship, increase their awareness of survivorship issues, and to conduct a detailed cancer history.
Having a pre-clerkship curriculum that includes PBL, innovative laboratory sessions, and a longitudinal “Doctoring” course facilitated the insertion of the modules. PBL survivor cases could be offered to course chairs to replace existing cases with similar learning goals but lacking a survivor focus. The “Doctoring” course chairs helped develop and implement the majority of skill-based modules in their course including the panel of cancer survivors, behavior change counseling, and advanced directives. The same implementation strategy worked for the clerkships as well. By involving clerkship chairs and site directors at UCSF, CDU, and UCLA in curriculum development, knowledge-oriented modules could be inserted in clerkships in internal medicine, surgery, and obstetrics/gynecology. A limitation to this approach is the need to negotiate for the needed curricular time for the integration of these new materials.