Background

Cancer Care Experience (CCE) is an oncology-focused hybrid didactic and clinical experience for the first and second-year undergraduate medical students that provides opportunities to further explore the field of oncology through active learning and knowledge-application exercises, skills development workshops, and direct interactions with content experts and patients.

The CCE was first introduced at Case Western Reserve University School of Medicine (CWRUSOM) in 2010 and was later introduced to Duke University School of Medicine (DUSOM) in 2015 and Penn State College of Medicine (PSCOM) in 2021. CCE was envisioned as an experience that led the learner through didactic sessions focusing on the patient experience of cancer prevention and screening, diagnosis, treatment, research, survivorship, supportive and palliative care, and end-of-life care while pairing students with mentors in the clinical learning environment to see this journey evolve in real-time with patients. Enrollment for the program was capped at approximately 45 students. The student body was divided into groups containing approximately eight students each, with each group following a patient case longitudinally throughout the CCE. Each didactic session led the students to explore the day’s topic through the lens of their patient’s case. An overview of each session is seen in Fig. 1. At the end of the program, the students would meet their patient and the patient’s family to gain an even deeper appreciation of the patient care journey and perspective.

Fig. 1
figure 1

Overview of each session in the program

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In 2021, the COVID-19 pandemic necessitated a transition to a virtual learning environment. The transition to an online platform created a unique opportunity for collaboration between DUSOM and PSCOM to deliver a seven-session, multi-site oncology-focused elective program for undergraduate medical students at both institutions. As a multi-site program, small groups consisted of students from both institutions, and speakers, facilitators, and patients were recruited from both institutions. However, as a virtual program, some original in-person aspects of CCE, such as in-person didactics and small groups; pathology review in the microscope room; meeting patients face to face; and clinical mentorship and shadowing and tours of facilities, were suspended due to social distancing and safety concerns and institutional policies limiting shadowing opportunities.

There have been few examples in the literature of multi-institution collaboration in medical education, with most focusing on graduate medical education [1,2,3]. To our knowledge, this is one of the few virtual, dual-institution elective undergraduate medical education programs in the literature. Therefore, we aimed to (1) assess the effectiveness of virtual learning, (2) assess the students’ perspectives on collaborating with students and faculty from another medical institution, and (3) assess the program’s impact on students’ clerkship preparedness and knowledge of the scope of practice of various professionals that treat patients with cancer.

Methods

An electronic voluntary survey of Likert-type statements using Qualtrics was distributed to CCE participants at the end of the program [4]. The ten-question survey assessed demographic information, comfort level with program learning objectives, personality traits from the modified Interpersonal Reactivity Index, clinical skills and understanding of the multidisciplinary aspects of cancer care, and perspectives of working with students and faculty from other institutions and the virtual platform. Students were asked the extent to which they agreed or disagreed with statements. Responses to these statements were ranked on a 100-point sliding thermometer scale (Supplemental Figs. 1-4). The Pennsylvania State University and Duke University Institutional Review Boards approved the study.

Data were analyzed using SPSS [5]. For the analysis, scores of ≤ 49 would indicate disagreement, while scores ≥ 50 would indicate agreement. Percent agreement was determined and reported as a frequency.

In addition, using the same 100-point sliding thermometer scale, students were asked about their preference for the following models: multi-institutional hybrid, multi-institutional virtual, single-institution virtual, single-institution hybrid, and single-institution in-person. Student preference was based on how far they moved their slider for each model. Each received a score of 1–5, with “1” being the highest preference. A Friedman Test was conducted with a p <. 05 to assess for significant differences between preferences for each model. Post hoc analysis with Wilcoxon signed ranks test was then conducted with a Bonferroni correction, resulting in a significance level of p <. 01. A multi-institutional hybrid model was defined as shared virtual experiences with home-institution in-person experiences. Students were not asked about their preference for multi-institution in-person models due to the low feasibility of such a program design at this time.

Results

Of the 64 students who participated in the CCE, a total of 25 (39%) started the survey, with 17 (26%) students completing it. Our results indicate that students largely agreed that they had developed an increased comfort, understanding, and clinical knowledge of cancer care (Table 1). Of note, students indicated that the program expanded their understanding of oncology care (100.00%) and raised their comfort in communicating bad news to a patient (88.20%). Additionally, 82.40% of students agreed that the program prepared them for clerkships. Students disagreed, however, that the CCE improved their history taking skills (47.10%) or their physical exam skills (17.60%).

Table 1 Frequency of student agreement with statements related to CCE learning outcomes
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In addition, participants were asked about their feelings regarding the online setting. Our results indicate that students largely agreed that the online platform was an effective tool at providing an educational experience for students. Students generally felt comfortable learning on the online platform (93.80%), but few students agreed that the online platform was an effective tool for engagement in large group sessions (37.50%) (Table 2).

Table 2 Frequency of student agreement with statements related to the online platform and multi-institutional approach
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Furthermore, student perceptions of the multi-institutional approach were assessed. Students generally agreed that the multidisciplinary approach was valuable to their learning (81.30%). Additionally, students indicated that their group dynamics with students from other institutions were positive. Students felt that they were able to make contributions to their groups (100%) and that this contribution was valued by group members (93.80%). Importantly, students largely agreed that they would recommend others to participate in future multi-interdisciplinary experiences with students and faculty from other institutions (93.80%). Similarly, they would encourage more education events including faculty and students from other institutions (93.80%) (Table 2).

Participants in the CCE responded to questions regarding their preference for the following models: multi-institution hybrid, multi-institution virtual, single-institution virtual, single-institution hybrid, and single-institution in-person. There was a statistically significant difference in preference between the different modes of instruction χ2 (4) = 38.315, p < 0.001.

Wilcoxon signed ranks test demonstrated no significant difference between preference for single-institution hybrid and single institution in-person (Z = −0.188, p = .851), multi-institution virtual and single-institution in-person (Z = −1.228, p = .291), and multi-institution virtual and single-institution hybrid (Z = −1.221, p = .222). There was a statistically significant difference in preference between multi-institution hybrid and single-institution in-person (Z = −2.718, p = .007), single-institution in-person and single-institution virtual (Z = -3.327, p < .001), single-institution hybrid and single-institution virtual (Z = -3.482, p < .001), multi-institution virtual and single-institution virtual (Z = −2.765, p = .006), multi-institution hybrid and single institution virtual (Z = −3.602, p < .001), multi-institution hybrid and single-institution hybrid (Z = −2.829, p = 0.005), and multi-institution hybrid and multi-institution virtual (Z = −3.681, p<0.001).

Discussion

CCE represents a potential model for inter-institutional collaboration in curricular approaches and delivery. CCE was viewed positively by our students. Our results are consistent with existing literature on utilizing a virtual platform for undergraduate medical education. A virtual radiation oncology clerkship was noted to be effective in increasing medical student interest and knowledge of radiation oncology, with the majority of students agreeing to recommend the clerkship to their classmates [6]. Similar findings were noted in a virtual general surgery clerkship, with students reporting increased personal interest in pursuing general surgery as a career and increased knowledge [7]. A virtual radiology clerkship found the highest satisfaction and engagement with small group activities [8]. Despite the abundant literature on virtual clinical experiences, less is known about virtual dual- or multi-institutional programs. A radiology-related virtual journal club for medical students and residents was reported to be well received [9]. A virtual otolaryngology sub-internship was reported to be successful in providing access and networking opportunities to prospective otolaryngology applicants [10].

From our experience implementing this program, and based on the results of this study, a multi-institutional virtual approach is both feasible and educational. From an implementation perspective, this approach has several advantages. Programs of this nature have the dual benefit of reaching more students and having access to faculty from both institutions. As the clinical demands and burn-out rates among physicians increase, a dual-institutional approach can relieve barriers that a single institution may face with a more limited faculty pool. More faculties made finding speakers and small group facilitators easier to lead the program. The multi-institutional aspect provides networking benefits to students, as they can work with medical students and faculty from another location. This can allow connections for mentorship and further collaboration, such as in research.

Furthermore, a virtual platform allows students and faculty the flexibility to participate in the program from any location. Still, a purely virtual approach only conveys some of the benefits that an in-person approach may have, such as shadowing opportunities. Additionally, virtual platforms may hinder the ability to engage students actively and may exacerbate Zoom fatigue, especially if students are already heavily interacting virtually for their school courses. The pros and cons of a purely online program complement our survey data that demonstrated a multi-institutional hybrid model was preferred by students. Such a program may include didactic and small group sessions on a virtual platform, while in-person experiences are done at the home institution. Students would still benefit from engaging with students and faculty from other institutions while gaining in-person experiences to supplement their didactic learning. Therefore, this approach offers an advantage over a purely virtual model since it maintains multi-institutional collaboration while creating opportunities for in-person experiences.

The limitations of this study include a low response rate and a smaller sample size due to only 1 year of data collection. Additionally, the dropout rate needs to be measured. However, these numbers are consistent with current literature on curriculum development in undergraduate medical education [7, 10]. Furthermore, the survey was only administered following the completion of the CCE, which makes it difficult to assess perceived improvement in the assessed areas. Future approaches would benefit from incorporating pre-and post-surveys, which could be utilized to capture additional data, as demonstrated in other studies assessing educational outcomes [11].

Conclusion

While there have been several examples in the literature of virtual learning experiences, our study demonstrates the feasibility of implementing a virtual multi-institutional educational experience. Most students agreed that the virtual platform was convenient, engaging, and had few limitations. They agreed that a multi-institutional program was valuable and would recommend it to others. From an implementation perspective, reaching more students and accessing additional faculty and resources were beneficial. This approach allowed individuals from geographically distant institutions to participate, highlighting inter-institutional strengths, and facilitating broader educational and mentorship opportunities. Our study demonstrates the benefits of multi-institution programs and hopefully will encourage more collaboration in the future to host multi-institutional programs.

Future directions for further developing the program include adding in-person instruction that was routinely a part of the original CCE program. While most of the experience can be replicated virtually, certain aspects are more enriching in person and maximize the learning experience. For example, touring the radiation oncology treatment rooms and meeting the patients and their family and friends face-to-face at the end of the program. This hybrid in-person and virtual multi-institutional approach would allow more students and faculty from geographically distant institutions to participate, highlighting inter-institutional strengths, and facilitating broader educational and mentorship opportunities while maintaining key in-person activities.