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Teaching Medical Students about Cancer through a Longitudinal Surgical Experience.

https://www.verywellhealth.com/
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cancer cells

Arundhati C Ghosh MBBS, FRCS, FACS, Assistant Professor of Surgery, HMS. Dept of Surgery, CHA
 



 

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Introduction
Undergraduate medical students rarely witness the course of any complex illness long enough to develop a comprehensive understanding of the disease or its effect on a patient. Cancer is an example of a complex illness in which students experience different aspects of care in a piecemeal fashion during different specialty rotations. In 2003, Harvard Medical School educators designed the Cambridge Integrated Clerkship (CIC) to allow students more continuous contact with their patients.1,2,3

Cancer Curriculum
The cancer component of the CIC curriculum allows students to follow patients with newly diagnosed cancer- at least one gastrointestinal and one breast cancer patient - across all venues and disciplines, throughout the year. On an average, students follow patients for 7 months, through 12 separate significant encounters across 4 different specialties.4 For the purpose of identifying true longitudinal care from prolonged inpatient stays, an entire inpatient hospital stay is counted as one encounter. 
 
At the end of the year, each student makes a formal presentation on one of their cancer patients. The students are required to include a concise “expert” summary of the clinical course of the disease and a focused area of review or analysis of a problem brought forth by the students’ longitudinal involvement in the patient’s care. Students present a wide array of topics. Examples include the impact of chemotherapy delay on mortality, with its disproportionate impact on disadvantaged populations, understanding microsatellite instability, genetics and clinical presentation of colon cancer in the young, in the context of answering a young patient’s query of “why me”, the effects of social determinants on outcomes of cancer care, the special needs of patients with intellectual disabilities when obtaining informed consent and discussing goals of care, and systemic and internal barriers (such as denial) to receiving prescribed care.
 
Study
We analyzed the end of year presentations to characterize which elements of the longitudinal care curriculum students described.
Sixty presentations out of a total of 67 were available for qualitative analysis. We derived codes from the data (codes were not pre-determined). We clustered themes emerging from the analysis of the presentations into domains. We found 33 individual themes, reflecting 5 major domains: Clinical Issues, Patient Characteristics, Systems Problems, Psychosocial Response to Cancer, and Existential Decision-Making (Table 1).5
 
Conclusion
Our analysis of these presentations revealed students’ rich view of their patients experience of cancer, of the healthcare system their patients encounter, and of the value of longitudinal learning. Students identified the context of care and patient-centered decision making as the most meaningful aspects of their learning within the longitudinal curriculum4.
 
Table 1.  Themes Covered by Students in End-of-Year Cancer Presentations

THEMES

# STUDENTS

Genetics of cancer

6

Cancer in the young adult

5

Cancer in the elderly

8

Premorbid psychological characteristics

11

Socioeconomic status

7

Screening

4

Diagnostic dilemmas

10

In-depth medical decision-making

38

Complex post-operative care

16

Outcome predictors

12

Use of complementary therapies

2

Cross-cultural communication

2

Financial barriers

7

Immigrant coverage

3

Healthcare team communication

4

Lack of primary care

3

Disjointed care systems

7

Professionalism

1

Importance of physician-patient therapeutic alliance

7

Conceptualizing cancer: patient's vs physician's vision

5

End of life decision-making

2

Uncertainty/helping patients deal with uncertainty

5

Patient autonomy in decision-making

13

Patient attitudes as barriers

8

Quality of life in cancer treatment

11

Ethical and philosophical Issues

3

Impact on family members

2

Role of family and social support in outcome

6

Psychological impact of disease on patient

15

Impoverishment due to illness as stressor

4

Resilience/empowerment

6

Concerns about sexuality/fertility

4

Gender identity issues

1

References