Over the last three decades, the medical school at Ben Gurion University of the Negev has developed a program that integrates clinical studies into the preclinical years (the first two years of a six-year medical program). Concordant with the medical school’s philosophy of training holistically oriented physicians, the students are exposed to ethical and emotional issues in the practice of medicine during these two years. As part of this program, the medical school instituted a one-week clinical course in oncology during the second year. The course presents a holistic approach to caring for patients with cancer, beyond the biological aspects of the disease usually taught during the preclinical years, and it exposes students to the issues associated with treating cancer patients and prepares them early in their education for dealing with these issues.
During the course, students interview cancer patients; attend lectures by various health care professionals who treat cancer patients, including oncologists and psychologists; participate in group discussions; review relevant oncology articles; and visit facilities where cancer patients receive treatment or support. Students discuss the psychological aspects of cancer with a psychologist treating cancer patients. They also discuss the ethical issues confronting oncologists after viewing the film “Wit” and during conversations with an oncology resident. Finally, the course includes “Art of Oncology” article presentations. These articles are published in the Journal of Clinical Oncology and on the whole focus on the psychosocial issues surrounding cancer and its treatment. They are written by clinicians, health care workers, patients, caregivers, and others who are affected by cancer.
Given that this approach is different from that taken by other medical schools, we sought to evaluate its impact, reception, and effectiveness by surveying students before and after they completed the course. We hypothesized that early exposure to the psychological and ethical issues surrounding cancer and its treatment would complement students’ understanding of cancer patients and their families, stimulate their empathy toward these patients, and strengthen their general knowledge of oncology.
Our evaluation included both qualitative interviews and a quantitative pre- and postcourse survey.
Following approval by the institutional review board at Ben Gurion University, four former students who completed the course in 2012 were invited via e-mail to participate in an in-depth interview about their experiences, impressions, and evaluations of the clinical oncology course. All four students agreed to participate and signed an informed consent form prior to the interviews, which took place in the spring of 2013. The purpose of the interviews was to gain insight into the students’ experiences to design an effective survey that had face validity with students who had taken the course in the past. We used a semistructured interview guide, and students were interviewed by a health psychologist (L.G.) who has extensive experience with qualitative research. We asked a range of questions pertaining to the impact the course had on the students, their feelings about the course, and their recollections of what was most and least significant for them. We digitally recorded and transcribed the interviews and then analyzed the text using a thematic analysis.1 The major themes from the interviews were culled within and across interviews and were used to design the survey.1
We generated preliminary survey items from the qualitative data analysis. Each member of the research team independently read and commented on the first draft of the survey, suggesting modifications as necessary. A second draft was then created and discussed, and further modifications to the items were made. Once all members of the research team had approved a final draft, we began the recruitment process.
All second-year students taking the oncology course in 2013 were invited to complete a pre- and postcourse survey. Participation was voluntary and had no impact on students’ grades or standing in the medical school. All students read and signed an informed consent form prior to filling out the survey.
The precourse survey was administered on the first day of class and the postcourse survey on the last day. The survey questions addressed the following domains: (a) experience with cancer; (b) emotional views of cancer (e.g., fear of cancer, comfort with death and dying); (c) capacity building toward cancer patients; (d) views of oncology; and (e) views of practicing oncology. Questions had either a multiple-choice design or a rating design on a scale of 1 to 5, where 1 indicated strong disagreement and 5 indicated strong agreement with the statement. Demographic questions included gender, age, place of birth, ethnicity, previous military/national service, marital status, and religious views.
We analyzed demographic data using descriptive statistics: mean ± standard deviation, median, and minimum and maximum. We also used chi-square and Mann–Whitney U tests as appropriate. Differences in numerical scores on the pre- and postcourse surveys were compared using Wilcoxon signed-rank tests. We examined the association between responses to the first three questions (i.e., “Have you ever been diagnosed with cancer?”; “Have you ever had a close acquaintance who had cancer?”; and “Have you ever had a close acquaintance who died of any disease?”) and demographic characteristics. We also examined the association between responses to two other questions (i.e., “Do you consider oncology challenging?” and “Are you considering practicing oncology in the future?”) and those to all other questions. All statistical tests were two sided, and statistical significance was defined as P < .05. We used SPSS (Version 21, IBM, Armonk, New York) to conduct all statistical analyses.
In total, 77 of the 86 students (90%) completed both the pre- and postcourse surveys. The remaining 9 either completed a pre- or a postcourse survey but not both, so we excluded their responses from our analysis. None of the respondents had been diagnosed with cancer, yet most had a close acquaintance who had cancer or who had died from any disease (see Table 1).
After taking the course, more students reported being concerned about ethical issues, being emotionally stirred by the course as compared with what they had expected before the course, being comfortable speaking with a cancer patient about death and dying, and being comfortable with the fact that the course dealt with death and loss and with “how to live with cancer.” Moreover, more students reported a fear of causing a cancer patient suffering because of a treatment yet were optimistic about being able to treat cancer.
Compared with responses to the precourse survey, more students reported in the postcourse survey that the oncologist should treat both the biological and emotional aspects of cancer. In addition, more students considered specializing in oncology, and more worried that they would need to treat patients with toxic or ineffective treatments.
We found no association between previous experience with cancer and other demographic characteristics. Students who viewed oncology as a challenging specialty were also more optimistic about cancer treatment in general, more at ease with the fact that the course dealt with death and dying, more pleased with the information provided in the course, and more worried about not being able to cure cancer patients in the future. More religious students were likely to consider practicing oncology in the future. No other demographic characteristics were associated with considering practicing oncology in the future.
In response to open-ended questions (i.e., “How do you think this course will affect you as a doctor?” and “What in your view has changed in your understanding of cancer as a result of the course?”), students indicated an increase in empathy toward cancer patients and a more holistic view of cancer in general. For example, one student commented, “Now I know what cancer patients feel like when they go through treatment.” Another remarked, “I learned that it’s essential to pay attention to the emotional aspects of patients when practicing medicine.” A third noted that the course taught him that “there is hope in the disease, both for the patient and for the doctor.” Finally, one student wrote, “In addition to learning about the specialty of cancer, I hope that as a doctor I won’t forget my humanity or the humanity of my patients.”
Our evaluation revealed some interesting and unexpected results. We are encouraged by the fact that students felt more comfortable talking to cancer patients about death and dying, were more optimistic about cancer treatment in general, and were more likely to consider becoming oncologists in the future after taking the course. These issues are especially pertinent across the globe today, including in North America2 and in Israel. For example, Israel is facing an urgent shortage of oncologists and oncology personnel. In 2010, the ratio of newly diagnosed patients to oncologists was 24,992 cancer patients to 180 oncologists.3 This figure does not include the thousands of cancer patients who were being treated for cancer at the time or receiving follow-up or palliative care treatment.
Our data show that early exposure to the clinical and emotional issues surrounding cancer can prime students to want to pursue an oncology career. We were disheartened, however, to discover that more students feared causing a cancer patient suffering and were concerned about prescribing overly toxic or ineffective treatments after taking the course. Although these changes in responses to the pre-and postcourse surveys indicate that we effectively transmitted the complex ethical, moral, emotional, and intellectual issues associated with being an oncologist to the students, they also indicate that we may need to provide additional discussion around these particular issues in the future to avoid causing excessive anxiety in students that may deter them from wanting to go into the field of oncology.
Our finding that students report increased empathy toward cancer patients despite increased trepidation about causing them suffering is promising. Such courses may be one way to counteract the decrease in empathy among students as they progress through medical school.4,5 In a recent article on the ideal undergraduate oncology curriculum for medical students in the United States, DeNunzio and colleagues2 concluded:
Students’ capacities to be empathic toward patients as well as good communicators among patients and fellow health care providers should not be neglected. The subjective nature of these topics make such determination more difficult but the anticipated benefits make the additional effort well worth it.
Our findings that students were able to communicate more easily with cancer patients and that they developed a heightened sensitivity toward causing patients unnecessary pain corroborate DeNunzio and colleagues’ conclusion and reinforce the need for medical schools to include this type of curriculum in their preclinical oncology studies.
Acknowledgments: The authors thank Arnold Schwartz and Lena Novack for their helpful comments on an earlier draft of this article.