Introduction

The outpatient medical learning environment poses numerous challenges for both learners and educators alike. Learners often face hurdles such as unclear expectations, insufficient orientation to staff and facility layout, limited opportunities for active participation, and the requisite medical knowledge and experience needed to navigate complex patient presentations. Educators, on the other hand, grapple with pressures stemming from patient overbooking, a lack of standardized objectives, and inconsistent feedback and evaluation mechanisms [1, 2]. Within the realm of surgical oncology, a subspecialty renowned for its complexity, junior learners may find themselves particularly overwhelmed. In such clinics, patients are present with a myriad of malignant and benign conditions affecting various organ systems, including breast, skin, gastrointestinal, colorectal, and endocrine systems. Studies have underscored the detrimental effects of inadequate feedback structures, evaluation biases, and the absence of clearly defined goals and objectives on the overall learning and training experience in this setting [3, 5].

Medical students on 3rd- and 4th-year rotations are tasked with conducting basic histories and physicals, interpreting laboratory and imaging results, and beginning to apply cancer staging, treatment, and surveillance protocols. Despite the Liaison Committee on Medical Education’s mandate for medical schools to offer both inpatient and outpatient experiences, no specific guidelines exist for a surgical outpatient curriculum for medical students [4,5,6]. Furthermore, there is a glaring absence of standardized recommendations for medical students and general surgery residents undergoing outpatient surgical oncology rotations, leading to insufficient preparation and negative learning experiences [7,8,9].

Recognizing surgical oncology as a core rotation according to the Accreditation Council for Graduate Medical Education (ACGME) General Surgery Program requirements, residents are expected to gain outpatient experience in patient evaluation, both pre- and post-operatively [10]. A variety of cancer-related topics are frequently encountered on the American Board of Surgery In-Service Training Exams (ABSITE) and the General Surgery Qualifying and Certifying exams. Following residency, many general surgeons will have a significant portion of their practice dedicated to the care of oncologic patients. Despite this, a recent survey of general surgery residents demonstrated over half of residents were only somewhat or less prepared to care for cancer patients with twenty-five percent not feeling prepared. Brenner and De Donno identified that a significant gap persists in formal education regarding fundamental aspects of chemotherapy, radiation, survivorship, palliative care, pain management, and cancer screening [11].

To address these deficiencies, it is imperative to develop a structured curriculum tailored to the needs of learners and educators. In a systematic approach described by Kern, conducting a comprehensive needs assessment is the foundational step in this process, aiming to identify knowledge gaps among medical students and junior residents, elucidate barriers and limitations faced by both learners and faculty, determine the optimal delivery mechanism for the curriculum, and assess the potential benefits and impacts on stakeholders, including learners, faculty, and patients [12]. The aim of this study is to assess the current education landscape in the clinic setting of surgical oncologists to inform and guide current educators and the development of a curriculum.

Methods

Design and participants

A cross-sectional survey was distributed via a web-based platform by the Research and Education Committee of the SSO in November 2021 and January 2022. Survey participants were surgical oncologists who are members of the Society of Surgical Oncology (SSO) who are currently employed at any institution in the United States and internationally working with both students and residents. Participants were recruited to complete the survey via email through the SSO listserv. Question types, areas of interest, and essential areas of clinical assessment were based on discussion with both surgical oncology-educators and non-surgeon educators of medical students and residents. Further clinical topics were gleaned by resident and medical student evaluations at the end of rotations by specific mention of topics of interest. An analysis of ABSITE performance of 59 residents (PGY1-PGY5) from 2 residency programs was done to examine areas related to cancer-care that were answered incorrectly by 2/3 of the residents. The survey was pilot-tested with surgical oncology-educators to obtain feedback and refinement.

Data collection and outcomes

The web-based survey was executed using a commercially available survey tool (Qualtrics™). Internal Review Board (IRB) exemption was obtained via the Augusta University IRB office prior to survey distribution. The survey was submitted to and approved by the SSO Research and Education Committee. This was disseminated on two occasions, three months apart, to SSO members who were registered on the SSO list-serve. The SSO estimates the membership listserv would distribute the survey to a total of 2798 Surgical Oncologists: 196 Private Practice Surgical Oncologists, 696 Community Surgical Oncologists and 1906 Academic Surgical Oncologists.

Collected data included survey responses to various questions regarding clinical environments, barriers, to education, goals for a curriculum, and potential outcomes for a curriculum. Survey data included yes/no responses, Likert-scale responses, and lists where respondents may check all that apply to them. Each list also included an “other” option where respondents could enter free text. The survey consisted of 27 questions related to the following areas: 6 questions on demographics, 13 questions on the learning climate and barriers, 4 questions related to physical exam, procedural skills, imaging, labs, and resources, and 4 questions on delivery mechanisms of the curriculum and impact. For the full survey tool, please see Appendix A.

Data analysis

All data, including partial responses, were de-identified and analyzed using descriptive statistics (mean, median) using Microsoft Excel, version 16.42 from the Microsoft Corporation in Redmond, Washington. Data processing and other statistical calculations were conducted using R, version 4.0.0 from RStudio based in Boston, Massachusetts.

Results

Demographics and current administrative and educational landscape

There was a total of 189 respondents to the initial survey with a response rate of 6.8%. Some responses were partially complete. A total of 121 respondents completed the demographic portion of the survey, of which 77 (63%) were male and 44 (36%) were female. The median age of all respondents was 49 years old and the median number of years which they had been instructing medical students and residents was 15 years. The most common leadership title respondents identified with was core faculty (47%) followed by division chair (30%). The majority (77%) of all respondents practiced in an academic setting (Table 1).

Table 1 Demographics of curriculum needs assessment respondents (n = 121)
Full size table

More than half (57%) of respondents reported spending between 8 and 16 h per week in the clinic. The majority of the respondents reported that there was no standardized curriculum offered to medical students and residents rotating through surgical oncology clinics (82%) and also reported that there was a need for such a curriculum (74%). The majority of surgeons reported not having any incentives for teaching (94%), that they were providing feedback (86%). Over half (53%) of participants noted having patients in their clinic who refused to see trainees. Respondents most commonly reported giving both verbal and written feedback to students (50%), with 47% reported providing only verbal feedback. Over 70% of respondents stated that they spent 20% or less time during clinic on teaching and feedback. While 81% of respondents report that having students and junior residents in clinic increases the total length of patient encounters, 71% would fill out an additional 5-min evaluation on a student or resident for one encounter on a premade form. Approximately, 57% of respondents reported that they felt that medical students were only somewhat or not at all prepared to participate in outpatient clinics (Table 2).

Table 2 Current educational landscape (n = 115)
Full size table

Barriers and priority of curriculum topics

Surgical Oncologists felt the three most common barriers faced by students and junior residents in outpatient surgical oncology clinics included a lack of time (59%), a lack of focused reading prior to clinic (57%), and a lack of curriculum and goals (54%). The three most common barrier believed to be faced by physicians in their ability to instruct medical students and junior residents were time constraints on the attending’s schedule (85%), the abbreviated period of time which learners spent on the rotation (61%), and too many patients (49%) (Fig. 1).

Fig. 1
figure 1

Barriers to Learners and Faculty (n = 112). *EMR (Electronic Medical Record) **H&P (History and Physical)

Full size image

The majority of surgeons currently teach the concepts which were questioned in our standardized curriculum survey. The three concepts which were ubiquitously taught were recognition for indications for surgery (95%), tumor staging (93%), and utilization of National Comprehensive Cancer Network (NCCN) guidelines (89%). The three concepts which respondents felt were most important to be included in a standardized curriculum were interpretation of ERCP/EUS (75%), how to evaluate a mammogram (75%), and how to perform an informed consent (74%). In 5 topics, the percent of responders teaching a topic was ≥ 15% lower than the percent who thought the topic should be included in a future curriculum (Table 3).

Table 3 Priority of curriculum topics (variable n = 93–109)
Full size table

Curriculum delivery and impact

Most respondents felt that 1–2 h a week would be the ideal amount of time for preparation for encounters in the outpatient setting (53%). The three most preferred means of delivery of curriculum were assigned reading (56%), in-person lectures (54%), and online self-guided modules (54%).

The majority (85%) of respondents reported that a standardized curriculum would improve preceptor feedback to students and junior residents. While only 65% thought that this type of curriculum would improve medical student shelf exam scores, 92% believed that it would improve the overall fund of knowledge for medical students. Over 73% of respondents believed that a standardized curriculum would improve resident ABSITE scores and 95% believed it would improve general resident knowledge. The majority of respondents believed that a standardized curriculum would have no effect on patient satisfaction (58%), but of those who believed there would be an effect, the most shared area where they believed there would be improvement was patient comfort (68%) (Table 4).

Table 4 Potential curriculum methods of delivery and impact
Full size table

No statistical difference was noted in a Chi-squared analysis between student (p = 0.54) and physician barriers (p = 0.4968). Responses were compared between those in practice for ≤ 15 (n = 62) years versus those in practice > 15 years (n = 59).

Discussion

This study is the first to address the multifaceted challenges encountered in educating trainees within the contemporary ambulatory surgical oncology setting. Surgical Oncologists, akin to many surgeons with intricate and elective practices, confront issues such as patient overbooking, time constraints, and inconsistent trainee engagement. Our survey of clinicians highlighted their endorsement of formalized curricula as potential aids for enhancing students’ and residents’ overall knowledge and examination performance. Notably, a significant proportion of respondents expressed concerns regarding trainees’ lack of clear objectives, focused readings, and adequate time allocation.

The majority of surgical oncologists felt that a standardized curriculum would improve feedback, medical student knowledge, resident ABSITE scores and knowledge, and patient comfort. Despite the plethora of educational resources available, including various texts and online platforms, none specifically cater to the clinical evaluation of oncology patients. Although the Surgical Council on Resident Education (SCORE) outlines essential oncology and tumor biology concepts for general surgery residents, a notable gap persists between theoretical knowledge and practical application [13]. This gap was further underscored by a 2020 study indicating that senior residents often felt ill-equipped to provide comprehensive cancer care upon completing their training [11]. Our study highlights areas that are currently taught by surgical oncologists and relevant to patient assessment and care in the clinic. While most topics were taught by over half of respondents, a disparity is noted in many areas that should be considered for future curriculum design including evaluation of mammogram and obtaining informed consents. It is notable that over 40% of respondents held a formal clerkship or residency program title. Identifying teaching gaps is potentially instructive for both clerkship directors and residency program directors to emphasize topics and skills that are fundamental to care for patients with cancer and commonly tested. Our study revealed that more than half of surgical oncologists endorse delivery of education via self-guided modules, lectures and/or assigned readings 1–2 h/week. Results from our study may further guide the time needed and the delivery methods and resources employed by training programs. Further, providing clarity around the most important topics and the goals and objectives of the rotation may enhance the clinic experience for both learner and patient and can improve evaluations and feedback.

The need for a curriculum is underscored from prior work from De et al. that highlighted how faculty self-ratings of teaching significantly exceed ratings of students and residents [3]. Like our study, the authors emphasized the need for structured interactions with faculty, defined roles, and consistent feedback. A similar survey of students, residents and surgical faculty demonstrated a clear discordance between student, trainee expectations and faculty expectations of their involvement in patient care [14]. Like previous studies, our findings stress the importance of structured interactions with faculty, clearly defined roles, and consistent feedback to optimize the trainee learning experience. The perceived lack of clear goals and curriculum structure emerged as a common barrier to effective trainee engagement, echoing sentiments observed in similar investigations.

Previous studies reported the poor correlation between subjective evaluations of medical students’ knowledge and objective performance during the surgical rotation [15, 16]. While all respondents to the survey reported giving feedback, for almost half of the respondents, this delivery was only verbal. Another study of resident trainees suggested that the majority of feedback received was verbal. While verbal feedback remains prevalent, its efficacy is hindered by challenges in both delivery and reception. Standardized methods are needed to enhance effectiveness and consistency across educational settings [17]. Most respondents noted that they would fill out a 5-min evaluation on one clinical encounter for a student or a resident if it existed. The willingness of respondents to utilize concise, encounter-based evaluations aligns with emerging trends such as Entrustable Professional Activities (EPA), which emphasize competency-based assessment in real-time clinical environments [18].

Several limitations temper the generalizability of our findings. This study is limited by its low response rate which may not accurately represent the population of educators in surgical oncology as a whole. The survey was distributed through the SSO to members where email follow up and direct contact for further clarity was restricted. Additionally, the survey’s length may have deterred participation and limited the depth of qualitative responses. The study was limited to surgical oncology members of the SSO and did not reach out to or include non-SSO members and/or general surgeons who may have a dedicated scope of practice in surgical oncology. Future work may identify a wider audience of surgical oncologists through other cancer and education focused societies which may improve generalizability of results. The predominance of respondents from academic institutions may introduce bias. For instance, the most agreed upon topic for inclusion into a curriculum involved EUS and ERCP. As the majority of respondents practiced in an academic setting, an analysis of the differences of responses between practice settings was not performed and may be informative in future research. Further, the conflation of medical students and residents in some survey questions necessitates future delineation of these distinct groups. Many areas of the survey that were queried (e.g. interpretation of imaging, drainage of abscess, informed consent) were relevant to not only surgical oncologists but surgeons with both elective and non-elective practices. As the barriers to education delivery and instructional subjects are common to surgeons across specialties, this study may inform similar work in other fields of surgery. Future research endeavors should strive to incorporate trainee perspectives to further inform curriculum development and assess its impact comprehensively. Despite these constraints, our study had completed responses by over 120 surgical oncologists, identified some gaps in the topics currently covered, and does explore a novel educational arena with findings that can be used to evaluate other surgical specialties and environments.

Conclusions

In conclusion, this study sheds light on previously unexplored aspects of surgical oncology education, including barriers to effective training, essential curriculum components, and potential impacts on trainees and patients alike. Enhancing the educational experience for medical students and residents during surgical oncology rotations is crucial for fostering knowledge acquisition, honing clinical skills, and improving overall cancer patient care. Moreover, these rotations expose students and junior residents to the foundational building blocks in comprehensive cancer care and play a pivotal role in shaping future career trajectories in surgical oncology [19]. Moving forward, our findings should guide the development of a tailored surgical oncology curriculum, with subsequent phases incorporating a modified Delphi technique involving stakeholder engagement and focus groups to refine curriculum design and assess its efficacy.