Background: Cancer is the second leading cause of death in the United States and thus is very prevalent, especially among older adults. Many cancer patients eventually reach the point where active treatment no longer provides any clinical benefit. It is during these times that oncologists must be well prepared and skilled to discuss prognosis, the pros and cons of ending active treatment, and end-of-life (EOL) care issues. Previous research has demonstrated that many oncologists are not comfortable having such discussions with patients. Such research suggests that the graduate medical education received by future oncologists may need improvement. However, many past research studies regarding the education of future oncologists in EOL had significant limitations.
Purpose: Therefore, the aim of this study was to improve upon past research and to survey the directors of all ACGME oncology fellowship programs in the United States (U.S.) to assess various aspects of EOL education with their programs. The current study assessed whether fellowship programs had a formal EOL curriculum, the EOL topics taught, how those topics were taught, the time invested in teaching, whether fellows’ knowledge and skills were evaluated, and various characteristics of the programs and the directors.
Methods: This study was observational, cross-sectional, and featured best practices in survey research, including the use of a theoretical framework. Participants were directors of all ACGME accredited oncology fellowship programs in the U.S. (n = 497). Data were collected via an online survey hosted by Qualtrics® Data collection spanned 12 weeks and included nine points of contact via email, fax, and phone. After deleting programs that did not meet the inclusion criteria, the final response rate was 19% (89/476). The investigators used IBM SPSS statistical package version 25.0 for data analysis. Descriptive statistics such as frequencies, mean, median, and mode were used for demographic questions and number of hours spent teaching. Inferential statistics included independent samples t-test, Pearson’s correlation, chi-square, and linear regression.
Results: The respondents were non-Hispanic (93%) Caucasians (62%). A plurality (42%) had less than 3 years’ experience as a program director. Most program directors (85%) believed that it was important for oncology fellows to learn about EOL topics and that adding more EOL education to the curriculum would improve patient outcomes (78%). The majority (62%) also believed that their upper administration supported EOL education and 27% reported that there were “no barriers” to adding more EOL topics to the curriculum. Furthermore, 55% of directors believed that other oncology programs across the country had an EOL curriculum.
Despite these positive beliefs and perceptions, only 35% of programs reported having an EOL curriculum. Another 12% of programs reported they were in the process of implementing one, and another 6% had thought about implementing one but had yet to do so. Ten percent of programs reported that they did not provide any teaching to fellows on EOL topics. Of programs that did offer EOL teaching, the dominant teaching method was “provided by the attending physician during rounds.” About half of programs did not have a conference curriculum in EOL topics and only 12% offered any online learning. Furthermore, 37% of programs reported that they did not formally evaluate fellows’ learning.
In terms of their own education and training in EOL, slightly more than 4 of 5 directors reported never having had a rotation in palliative care or hospice care. More than half believed that the quality of EOL education currently being offered in medical schools and residency programs was “below average” or “poor.” Furthermore, approximately 40% lacked confidence to teach/mentor in EOL. Despite the small proportion of programs with a curriculum and directors’ own lack of training and confidence, 36% of them rated the quality of EOL education in their own program as “above average” or “excellent.”
Only one director factor was associated with having an EOL curriculum. Directors’ collective efficacy score was moderately and positively associated with having an EOL curriculum, r(80) = .306, p = .006. The higher directors’ collective efficacy (factor 2) the more likely a program was to have an EOL curriculum. Conversely, one program factor had a moderate, negative correlation with having an EOL curriculum - the number of FTE faculty r(82) = .0278, p = .012. The fewer the number of FTE faculty, the less likely it was for a program to have an EOL curriculum. Results of our regression analysis indicated that none of the following factors predicted which programs had an EOL curriculum: directors’ self-efficacy, perceived barriers, directors age, sex, race, years in position, and medical degree.
Of the 19 EOL topics listed on the survey, only three programs (4%) did not teach any of them. The majority of programs (58%) provided at least some teaching in the 19 topical areas. The three most common teaching topics among programs were:
• How to discuss prognosis with patient and family members (85%)
• How to deliver bad news in a sensitive way to patients with cancer (85%)
• How to make a timely referral to palliative care/hospice care for the patient (76%).
The category of teaching topics that was neglected the most was socio-cultural topics related to EOL. Nearly 20% of programs did not offer any teaching in this category. The three least common teaching topics were:
• How fellows can stay current in their EOL knowledge and skills (23%)
• Knowledge of various religious and cultural aspects of dying (29%)
• Knowledge of grief, bereavement and mourning (41%)
Most fellowship programs in our study did not have rotations in palliative and hospice care. Only 15% had a required rotation in hospice care and 23% offered an elective rotation. In palliative care, 32% of programs required rotations and 34% offered an elective rotation. More than half of programs, (55% to 59%) did not evaluate fellows’ learning on these rotations or did not know if fellow’s knowledge was evaluated.
Conclusion: The EOL education and training provided to fellows among the programs that reported needs to be improved. Nearly 2 of 3 programs did not even have a curriculum and the majority did not offer rotations in hospice or palliative care. Furthermore, the majority of programs did not evaluate fellows’ knowledge or competence.