Applied Radiation Oncology’s latest blog covering today’s issues in oncology
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John Peterson, MD, is a 2022 graduate of the University of Utah School of Medicine and an incoming radiation oncology resident at the Moffitt Cancer Center in Tampa, FL. |
Battling Bunk: Cancer Misinformation’s Impact on Patients and How Providers Can RespondMay 2022 The “infodemic” that stalks the ongoing COVID-19 pandemic might be the most prominent recent example of the harmful impact of health misinformation, but it is in no way a unique phenomenon—or, for that matter, a new one.1 Complex and frightening diseases, like cancer, have long been the target of medical misinformation and ineffective treatments. Therapies that are not part of the standard of care include “alternative” and “complementary” therapies, sometimes combined under the umbrella term “complementary and alternative medicine” or CAM. While similar, these terms are distinct. Complementary therapies are used together with the standard of care, often for symptom management.3 For example, if a cancer patient manages their chemotherapy-induced neuropathy with acupuncture but continues to follow with their oncology team’s prescribed treatment, acupuncture would constitute a complementary therapy. Conversely, alternative therapies are used in lieu of the standard of care.4 If our hypothetical patient opted to treat their disease exclusively with acupuncture and abstain from medically indicated treatment, acupuncture would become an alternative therapy. In short, the way in which therapies are applied largely determines whether they are alternative or complementary. The NIH reports that about 1 in 3 adults and 1 in 8 children in the US use CAM, suggesting that while it may not be part of the standard of care, CAM is well within the cultural mainstream.5 Despite its prevalence, CAM use poses risks of physical and financial harm. Mortality rates among cancer patients who use CAM are significantly higher than those who do not.6,7 Even seemingly benign herbal supplements used as complementary therapies are known to have adverse interactions with chemotherapy.8 The financial harm associated with CAM use can also be high, although research into the topic remains sparse.9 Together with other researchers, I have analyzed hundreds of online fundraising campaigns written by individuals seeking alternative cancer therapy. Their stories hint to acute financial strain. One person solicited donations “so their family does not have to take a mortgage out on their home to fund it.” Another sought alternative therapy despite them being someone “whose savings are gone, with credit card debt [in the thousands].” Yet another individual explained that they were forced to turn to online crowdfunding to help pay for alternative therapies since they “cannot get funds or loans from banks” due to their already poor credit. Avoiding low-quality cancer care is key to minimizing financial toxicity.10 Tragically, using CAM does the exact opposite; it often involves substantial out-of-pocket costs and correlates with poorer health outcomes. Engagement with cancer misinformation often begins with good intentions. After receiving what about half of US adults consider to be their most dreaded diagnosis, patients and caregivers often turn to the internet for answers and hope.11 Many find community through online support groups on social media. Unfortunately, much of the information shared in these spaces is inaccurate. In a 2021 study by Johnson and colleagues, cancer experts reviewed the 50 most popular English-language social media articles on breast, lung, colorectal, and prostate cancer to evaluate their veracity and safety. Over a third contained misinformation and 30.5% contained statements classified as medically or financially harmful.12 Previous research has established that falsehoods spread further, faster, and to a broader audience than truth, and there appears to be no difference with cancer.13 Unfortunately, Johnson et al found that engagement (eg, likes and shares) was significantly higher for misinformation than for fact, and higher still for articles with harmful misinformation.12 Algorithms designed to maximize the amount of time users spend on platforms contribute to the problem by selecting for emotional reactivity rather than truth.14 Misinformation is often presented in emotionally compelling narratives, which research has found to be highly memorable and persuasive.15 To make matters worse, many CAM providers gain credibility by co-opting scientific medical language, a behavior known as “scienceploitation,” and citing publications in predatory journals.15 Their false claims are, in turn, referenced by others online. For example, one crowdfunding campaign emphasized that a clinic provided “an alternative cancer therapy ... that has a 98% success rate.” Another described a CAM practitioner as “a pioneer” who “has been successfully treating cancer patients” for decades. Repeated exposure to these narratives raises the profile of ineffective therapies, and soon familiarity is easily mistaken for validity.16 This constellation of factors means that too often, the internet’s reply to a sincere request for useful cancer information is an intoxicating cocktail of hearsay and predatory advertising crafted for clicks. Fortunately, medical professionals are well positioned to counter this maelstrom of misinformation. A national survey of US adults conducted in May of 2020 found that more than 90% trusted hospitals and physicians.18 While public confidence has decreased since then, the Pew Research Center’s 2021 survey found that 78% of US adults still report either “a great deal” or “a fair amount” of confidence that medical scientists act in the best interests of the public.17 Strong interpersonal skills appear to be key to this trust; patients report that they have confidence in physicians who listen, deal honestly, express caring, and are considerate of their unique circumstances.19,20 The importance of a strong therapeutic alliance cannot be overstated. Although many cancer patients use CAM, a fear of criticism often keeps them from telling their doctor about it.21 Moreover, patients’ motivations for pursuing CAM are complex and can change over time,22 Many are drawn to CAM because they want holistic care, so it is encouraging that a growing number of cancer hospitals are finding ways to safely and effectively integrate complementary therapy into care plans.22,23 Others patients grow frustrated with conventional therapies’ adverse effects or feel that they must continue to fight on after the standard of care has proven ineffective.22 A growing number of learning resources, including those available through the American Society for Radiation Oncology (ASTRO), teach how to sensitively navigate complicated clinical scenarios.24 Training such as these can help medical providers build upon broad public trust and facilitate open and empathetic clinical conversations. Medical professionals can also connect with cancer patients on social media.25 When incorrect information is shared, either in clinic or online, clear correction is shown to be an effective response, though repetition may be necessary.26 Just as personal stories are used to spread misinformation, they can also be used to illustrate of the harms of alternative therapy and celebrate the efficacy of evidence-based care. When discussing treatment options with patients, find ways to teach visually or experientially. Educational materials, especially those with images and pictograms, have proven highly effective at communicating information and countering anecdotes.27 By listening to patients, connecting with them emotionally and digitally, and teaching powerfully, cancer care providers can respectfully and effectively respond to misinformation. References
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Nadia Saeed, BA, is a fourth-year MD candidate at Yale School of Medicine, Class of 2022. She serves as the Medical Student Representative for Applied Radiation Oncology. |
Communication Skills Training in Radiation Oncology ResidencyMarch 2022
Empathetic and effective patient-physician communication has been linked to a number of positive outcomes including improved patient compliance and satisfaction, decreased risk of medical errors and malpractice lawsuits, and less physician burnout.1-3 This benefit is reflected in the Accreditation Council for Graduate Medical Education’s (ACGME) inclusion of communication skills as an educational requirement for residency and fellowship programs. Oncology residents overwhelmingly recognize that communication skills are integral for their practice and generally feel comfortable in these skills overall.4 However, several areas of communication in oncologic care have been identified as especially challenging and likely warrant greater attention during training. These include shared decision making, code status discussion, discussion of complementary or alternative treatments, and challenging aspects of illness trajectory including disease progression, poor prognosis, and maintaining hope.2,5 For example, it has been shown that while oncology residents and program directors believe code status communication to be particularly important in oncology, only a minority of residents report receiving formal evaluation in this area, with lack of evaluation tools, time, and resources identified as barriers to teaching this skill.6 In a survey analysis, only slightly over half of oncology residents responded that they were familiar with the term “shared decision making” while less than a third knew its meaning.4 Some formal communication skills courses in oncology have been developed, although their integration into radiation oncology residency training has not yet been standardized. For example, an 8-module course on communication in oncology practice for palliative and oncology fellows and radiation oncology residents was shown to significantly improve global communication skills. Delivered over 2 months, the course consisted of objective structured clinical exams (OSCEs) on breaking bad news using standardized patients, weekly didactics and role play.2 Additionally, ASTRO has offered a course in improving doctor-patient communication skills, which covered breaking bad news and empathetically discussing transitions in care among other challenging topics in communicating with patients with serious illness; participants learned how to apply specific communication skill sets including the use of NURSE statements (Naming, Understanding, Respect, Support, Empathy), SPIKES approach (Setting, Perception, Invitation, Knowledge, Emotion/Empathy, Summary/Strategy), and REMAP (Reframe, Expect emotion, Map the future, Align with values, Plan for the future).1 Efforts have also been made in training faculty members to teach communication skills to trainees. Oncotalk Teach was created as a faculty development program to provide expertise in teaching communication skills to oncology fellows. Consisting of small-group practice sessions with simulations, reflective teaching exercises, and videotaped teaching encounters, the course focused on goal setting, trainee engagement, and reflective feedback.7 Training in communication skills is also essential for optimal functioning of the interdisciplinary team, with important implications for healthcare delivery. The value of interprofessional training in radiation oncology is being increasingly recognized, with efforts being undertaken to provide these experiences for different members of the radiation oncology team. For example, participation in interprofessional conferences including daily peer review by radiation therapy and medical dosimetry students has been shown to increase comfort in speaking with other team members including resident and attending physicians and physicists.8 Similarly, an interprofessional education curriculum for medical assistants led by radiation oncology residents was shown to improve clinical understanding and perceived empathy for patients.9 While such interprofessional experiences exist for nonphysician members of the radiation oncology team—including nurses, dosimetrists, radiation therapists, and medical physicists—evidence suggests there are limited opportunities for physicians to learn formally about other professions in a similar way.10 Given that inefficiency in clinic and disorganized patient care can result from misunderstanding of team members’ roles, such interprofessional experiences have important implications for quality and safety. Expansion of existing interprofessional workshops and development of formal shadowing programs for residents would facilitate ease of communication with other members of the radiation oncology team.11,12 Moreover, these skills may be taught using standardized tools such as simulations aimed at improving interprofessional communication skills.13 Leadership training—an area garnering increased attention in radiation oncology residency training—may also cover competencies essential to interprofessional communication such as self-awareness, social awareness, and conflict management.14 Communication skills are essential to navigating the emotionally nuanced and complex patient conversations in radiation oncology. Both the content and delivery of information to patients with cancer can profoundly influence their treatment decisions. At the same time, effective communication is necessary for efficient functioning of the interdisciplinary radiation oncology team. Formal integration of communication skills training through implementation of existing interventions and expansion of communication curricula during residency can improve preparedness in this fundamental competency and significantly impact patient care. References
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Nadia Saeed, BA, is a fourth-year MD candidate at Yale School of Medicine, Class of 2022. She serves as the Medical Student Representative for Applied Radiation Oncology. |
Rethinking the Preliminary Year: The Argument for an Integrated Residency in Radiation OncologyNovember 2021 There has been a progressive shift toward adopting an integrated residency program structure among many specialties that had traditionally required a separate internship year;1 however, this element of the radiation oncology training landscape has remained largely unchanged. Although a small number of radiation oncology programs have a linked intern year and are thus considered categorical, most begin at the PGY-2 level, requiring applicants to apply to internships separately. While the transition toward integrated internships has been gradual and largely program-dependent in many specialties, some recent examples of a consolidated effort link the PGY-1 year with advanced training. For example, the Accreditation Council for Graduate Medical Education (ACGME) has requested all ophthalmology residency programs become integrated or joint by July 2023.2 There are several potential advantages to similarly implementing a universal integrated program structure in radiation oncology. Preliminary year training is currently heterogenous among radiation oncology residents, who have the option to complete their internship in any number of specialties including internal medicine, family medicine, surgery, obstetrics and gynecology, pediatrics, or with a transitional year.2 An integrated program structure could introduce standardization across PGY-1 training and, more importantly, could be leveraged to tailor the first year of residency toward clinical experiences considered valuable for radiation oncology. For example, surgical exposure and gross anatomy education have been identified as valuable competencies for radiation oncology but are not typically included in the standard residency curriculum.3-6 Similarly, many radiation oncology residents have reported a need for dedicated diagnostic radiology training during residency.7 A PGY-1 year tailored specifically for radiation oncology could provide the opportunity for formal education in these areas. It should be noted that a minimum of 9 months of direct patient care during the preliminary year is required by the ACGME;2 still, it is likely that many of the rotations beneficial for a career in radiation oncology (such as surgical oncology, ENT, medical oncology, etc.) would fall under this heading. One might also consider the possibility of earlier introduction to radiation oncology during the intern year. For example, PGY-2 ophthalmology residents who completed ophthalmology training time during their internship reported greater preparedness in formulating ophthalmic diagnoses and performing the ophthalmic exam.8 The ACGME currently allows for up to 3 months of radiation oncology rotations during the preliminary year, although typically only transitional year programs include the substantial elective time needed to capitalize on this (even then, not all programs have an affiliated radiation oncology department and many also have their own requirements for how elective time can be spent).2,9 Standardizing radiation oncology exposure during the PGY-1 year may be advantageous, especially with the continued emergence of newer treatment modalities. Additionally, completing the preliminary year at the same institution as radiation oncology residency could facilitate earlier mentorship and research opportunities. Given the longitudinal nature of clinical research, such a program structure may enhance productivity while allowing residents to explore different research interests ahead of their dedicated research blocks—something that would be particularly beneficial in residencies with less dedicated nonclinical time.10 Moreover, a linked PGY-1 year would also allow for earlier integration into the hospital system where one’s advanced training will be completed. Prior familiarity with the electronic medical record (EMR), hospital layout, and other departments and services one will be working with and consulting on would likely ease the immense transition from the PGY-1 to PGY-2 year. It should also be highlighted that linking the intern year with advanced training would help reduce the significant financial and logistical burden associated with applying to residency. Medical students currently spend hundreds—even thousands—of dollars on residency applications;11 for students pursuing radiation oncology, this includes the cost of additional applications for separate internship programs. While the switch to virtual interviews in the wake of the COVID-19 pandemic has helped mitigate the substantial overall cost of the residency application process, the cost of the application itself should not be ignored—especially if some form of in-person interviewing eventually resumes. Reducing the overall number of applications necessary to submit would be a step closer to decreasing the significant economic barriers inherent in this process. Additionally, the cost of potentially moving twice—once for internship and again for advanced training—should be considered as well. Some advantages to maintaining a residency structure with separate internship and advanced training are worth noting. First, while there is likely an overall benefit to introducing standardization across the PGY-1 year, the current flexibility in choice of internship type allows residents to tailor their training to align with their clinical interests. Additionally, residents may capitalize on the geographic flexibility of a non-integrated internship to explore a different region of the country or spend a year close to home or family. Moreover, many argue that a full year of internal medicine or surgery provides the opportunity to build broad clinical skills before embarking on a highly specialized career trajectory. Still, these factors should be weighed against the many educational, financial, and logistical benefits of transitioning toward an integrated program structure in radiation oncology similar to that of many other specialties. REFERENCES
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In addition, the degree to which the social networks of Web 2.0 amplify inaccurate cancer information can be staggering. Look no further than the 2020 American Society of Clinical Oncology (ASCO) Cancer Opinion Survey, which found that over a third of US adults believe that cancer can be cured through alternative therapy alone.2 What does the normalization of alternative therapy mean for cancer patients and how can medical professionals respond in a way that is both effective and respectful? Let us begin by defining important terms.
Communication skills are well-recognized as an essential competency in practicing medicine, with increased acknowledgment of the need for formal training in this domain in both undergraduate and graduate medical education over the last several years. The importance of these skills is amplified in oncologic specialties given the frequent need to communicate emotionally challenging and complex medical information regarding patients’ disease courses. Moreover, the interdisciplinary and multidisciplinary nature of radiation oncology in particular necessitates effective communication strategies to ensure successful functioning of a dynamic oncologic team. While these skills can be observed in the clinical setting from working with attending role models, there is a significant benefit to formal training in this area during residency. While some curricula in communication in oncology have been developed, there is heterogeneity in the integration of these skills in radiation oncology residency. Standardization of formal communication training in residency as it relates to both patient care and interprofessional collaboration is essential and has the potential to improve care delivery and patient outcomes.