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Blended Learning for Oncologists and Their Colleagues

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Part of the Sustainable Development Goals Series book series (SDGS)

Abstract

Oncology is a rapidly developing field with a high societal impact. It comprises more and more complex knowledge, more sophisticated patient management, and truly interdisciplinary collaboration. Addressing the needs of oncologists is important to satisfy the increasing need for updating their knowledge about new medicines and treatment strategies together with managerial aspects of the medical profession and practice while balancing personal needs for well-being. Out of the many options, a blended learning, degree-awarding study program is a possibility combining high flexibility with only few fixed appointments and a profound net-working experience. I will describe in this chapter the ESMO (European Society for Medical Oncology)/ASCO (American Society of Clinical Oncology) recommendations for a global curriculum in oncology, how their educational part was translated into online learning modules, and how soft skill training for presentation, communication, and negotiation together with personal coaching resulted in a network of oncology professionals gearing toward better cancer patient care everywhere in the world.

Keywords

  • e-Learning
  • Blended learning
  • Sustainability
  • Medical training
  • Oncology
  • Advanced

ESMO/ASCO Recommendations for a Global Curriculum in Medical Oncology

The first recommendations for a global curriculum in medical oncology were published and distributed worldwide by a joint taskforce of the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) in 2004 (Hansen et al. 2004). These recommendations were comprehensively updated in 2010 and 2016 (Dittrich et al. 2016). Their currently available form has been endorsed by 51 different professional organizations linked to oncology and translated into 8 languages different from English thereby making it accessible to professionals throughout the world (ESMO 2021).

From the start, the recommendations covered all aspects of oncology training such as the structural prerequisites of a proper training program, the contents, and the skillset that trainees should strive to achieve. The most recent edition of the curriculum was supplemented with an extensive logbook detailing the required procedures (ESMO 2021). On 240 pages, items are categorized according to the respective area, entity, or essential procedure, and a before/after assessment is done by the direct supervisor/mentor. The assessment is to be countersigned by the trainee and the head/director of the respective department or clinic. Many specialists from both scientific societies, ESMO and ASCO, have contributed to this very fine-grained curriculum and created a blueprint for entire generations of oncologists. I cannot emphasize enough the outreach effect of this curriculum on specialists all over the world.

A very important innovation was introduced into the third edition in 2016: the level of competence (ESMO 2021). Three different levels of competence have been defined: awareness, knowledge, and skill. While it is easy to be aware of a fact, a concept, or a procedure, it is an entirely different level to really know or even master them. How can a new level of competence be reached? Of course, clinical training should teach the skills to competently treat cancer patients and provide not only medication but also any support that the patient or their family might need. But it must be accompanied by didactic training to explain and internalize the concepts of the underlying biology, accompanying diagnostics, treatment plans, entity-specific issues, as well as training for professional communication with patients, peers, and other stakeholders in the cancer care continuum.

Of MOOCs (Massive Open Online Courses) and SPOCs (Small Private Online Courses)

Both ESMO and ASCO are providing didactical online material on a pay per service rate at their websites so that interested professionals can assess the videos and quizzes in order to learn points outlined in the global curriculum. There are discounts available for learners in training as well as for learners from low- and middle-income countries (LMICs). As with professional life in general, these teaching materials are available in an asynchronous manner, that is, learners may access them depending on their schedules and preferences. Herein lies also a major hindrance in the use of these materials: learning is self-paced and enforced by board certification or maintenance of certification examinations (Yuan and Powell 2015). An explorative analysis by ASCO showed that the group of learning professionals is highly heterogeneous in terms of learners’ preferences (George et al. 2021). Many professional societies require a documentation of continuous medical education as part of ongoing licensure. These activities may comprise in-person events like meetings and courses and electronic activities like quizzes and didactic videos. There are country-specific differences in the requirements for admissions to certification examinations or maintenance of certification making offered online materials by ESMO or ASCO less palatable to physicians outside of the scientific society’s country/region.

What can be done to offer a comprehensive didactic education in oncology? The conventional route would probably be to establish a dedicated structured PhD program for oncologists and provide the necessary didactic teaching. Another option would be to guide trainees and other interested professionals didactically in a more decentralized manner but guide them nonetheless. The question is as follows: by what didactic approach and with what level of supervision?

With the coming of age of information technology (IT) and the Internet, possibilities to share knowledge have grown exponentially. The openness of the Internet led also to attempts of making education more equitable, at least to the outside viewer (Yuan and Powell 2013). One of the results was the generation of MOOCs (massive open online courses). These courses contain didactical material and address learners’ needs in terms of contents. Frequently, they are offered by established high-ranking universities building on successful in-person courses or serving as both an outreach and a teaser, edX courses, for example. Many of these courses, either free of charge or available at affordable prices, had many subscribers to start with and rather little numbers of finishers owing to the fact that curricular obligations like assignments posed barriers for the learners involved in these courses. Another challenge is that the registration for MOOCs is done technically, and there is no person-to-person contact involved at first, likely to result in less identification with the goals and lower adherence. Many programs do involve group work and group assignments, though, and there is people-machine-machine-people interaction involved making the course curricula more adapted to the learners’ needs for human communication. The general didactics of MOOCs are based on andragogy, just like every “normal” course one might follow in person at university. They are oftentimes even more learner-centered than a conventional lecture in a medium university like ours, with approximately 350 students in order to keep the learner engaged as long as possible.

SPOCs (small private online courses) are different. Being small brings a different level of engagement between course organizers and learners. The privacy is usually enabled by paying tuition to cover the costs of the entire endeavor, that is, the personnel for organizing and running the course, particularly tutors to engage and activate the learners. Many universities offer such courses, and some of them are not small at all. These courses very often are conducted in a setting that combines attendance in person with online learning phases and is therefore called blended.

At Ulm University, we have currently seven study programs that are built upon the blended learning concepts, and the Advanced Oncology study program was the first among these. Why was it established? What are the benefits for the learners? Is there a benefit for the university?

A Broader Vision

It started with a true pioneer in his field, Theodor Max Fliedner (TMF). He was trained in internal medicine, particularly hematology. Early on in his career, he investigated the effects of radiation on the bone marrow and continued to do so beyond his retirement. He was one of the pioneers of stem cell research within the context of leukemia. One of his inventions, the “Ulmer Zelt” (Life Island), is still being used in order to keep patients germ-free after bone marrow transplants (Hoelzer and Gale 2016). TMF was among the founders of Ulm University, was the university’s president from 1983 until 1991, and worked afterward as a medical liaison for WHO by chairing the Global Advisory Committee on Health Research between 1993 and 1997 (Weber-Tuckermann 2016). In other words, he was at ease with the subcellular, cellular, organismal, and all organizational levels of cancer and cancer research.

As can be taken from his final report to WHO, things were clear to TMF from an epidemiological perspective: registries should be established to report incidence and mortality of cancer in a population. Then physicians must find, test, and apply new treatments to lower incidence and mortality. Their outcomes are measured by reporting to registries and benchmarking the data; comparing them with the previously reported ones; taking action depending on the outcome of the reporting, that is, being satisfied with the achievements or being dissatisfied with the achievements; and engaging into further iterations of the cycle (World Health Organization 1998), if only things were not muddied by the tiny little details!

In “the” agenda, TMF also described telehealth approaches and distance learning using the (French) term telematic (World Health Organization 1998). And this is actually what he focused on during the last years of his life, to lay the foundation for a network of oncologists, who want to further educate themselves to conquer cancer in their countries. Problems were challenges and to be solved and that was that. In project management, we often talk about stakeholders and ownership, and this was practiced by TMF by engaging in wider discussions about long-term goals or even visions. Those, who had worked with him, know that TMF ensured that his visions materialized.

The Ulm University Advanced Oncology Study Program

In 2008, Ulm University successfully applied for a grant for establishing its first blended learning program, Advanced Oncology. At the core of this degree-awarding study program are the four online modules “Interdisciplinary Oncology,” “Clinical Research,” “Advanced Therapies and Integrated Concepts,” and “Management.” These modules are embedded in a teaching concept that covers soft skills and knowledge but also networking activities.

Summer School “Challenges and Introduction”

During this—usually—in-person meeting, organizers and students meet for the very first time. Students are being welcomed and formally enrolled, that is, they present the original documents that were the basis for their admission to the study program. This is followed by the mutual introduction as well as the introduction to all issues pertaining to the organization of the study program including the Master’s theses. The students learn the use of the Moodle-based learning platform, how to interact with the lecturers and each other, and how to take the mandatory pre-exam assignments that are required for the admission to the module examinations. This kickoff meeting is very inspirational, and we have optimized it over more than 10 years that we run the program. According to the students’ wishes, introductory lectures by module responsibles were reduced in favor of more interactive aspects like the pathology catch-up and workshop as well as a first introduction of the health economic assessments. In order to accompany this professional growth, we also provide personal coaching throughout the time of studies if requested by the students. The coach introduces herself and her coaching method during this seminar. Starting in 2019, we welcomed a colleague of the WHO Classification of Tumours Group, who introduces students to evidence-based medicine and contributes to the workshop by teaching critical appraisal of published literature. The other topics of the workshop relate to molecular diagnostics and digital pathology. All this is then observed on a professional level during a visit of one of the tumor boards of the Comprehensive Cancer Center Ulm (CCCU), usually the leukemia and lymphoma board. Students return to their home countries, well-instructed and primed for the things to come.

Module “Interdisciplinary Oncology”

This module is divided into the courses “Cellular and Molecular Biology of Cancer,” “Diagnostics,” “Principles of Therapy and Treatment,” and “Epidemiology.”

The first course comprises a bouquet of lectures that address the underlying biology and biochemistry of cancer formation, evasion, and metastasis. Besides the obvious relation to the study subject, this course serves the didactical purpose to reactivate learning strategies of the students and to encourage them to ask the expert lecturers questions pertaining to the subject matter. All lecturers can provide knowledge and guidance beyond their lectures, and this is essential to overcome long existing reluctance to the matter at hand for most of the physicians studying with us. Scientists usually have less trouble following these lectures. This course, like all the subsequent ones, needs to be passed in order to be admitted to the module examination.

The course “Diagnostics” covers topics from histopathological assessment of specimens to whole-body imaging. Many aspects of the previous course like the molecular targets are automatically rehearsed since their diagnostic and/or prognostic value had been clinically proven. During the course “Principles of Therapy and Treatment,” students familiarize themselves with all aspects of treating tumors or patients with tumors in general, starting from immunotherapy and ending with genetic counseling and stem cell transplantation. Lastly, our dedicated epidemiologist explains in detail cancer statistics, registries, and the resources offered by the International Agency for Research on Cancer (IARC) during the course “Epidemiology”.

By the end of the winter term, students return to Ulm to take their first online examination; attend a workshop on molecular diagnostics, one on scientific writing; and start working toward the “Biometry” course of the upcoming module. Their favorite part, however, is an entire day of soft skill training with a professional communication trainer. Using direct feedback by peers supported by individually recorded videos, students polish their rhetoric strengths and are able to make a better first (and second) impression.

Module “Clinical Research”

This module covers the entire topic of good clinical practice (GCP), biometry, and project management together with ethical issues that may arise during the proper conduct of clinical research.

The course “Biometry” empowers the students to understand and properly handle numbers linked to anything that is measurable. Even though this course is feared by many students in the beginning, the overwhelmingly good results in the module examinations speak for themselves. “Clinical Trials” covers all aspects of clinical trials, starting from the concept of evidence generation, detailed descriptions of the different and particularly critical phases of clinical trials, and the transfer of study results into clinical practice. This is followed by the short, but very important, course “Ethical Aspects,” detailing the legal and ethical obligations of researchers and how to prevent and detect scientific misconduct. Observational studies are introduced as well as the principles and proper conduct of systematic reviews and meta-analyses. Finally, students learn aspects of project management and biosimilars and rehearse health economic evaluations.

After a thorough in-person repetition of all things in “Biometry”, students take their examinations and visit a production plant for biosimilars. The third seminar marks the point in time, when students have finished half of the curriculum. The students meet the elder class for the first time and network with them. Also, they refine their communication and negotiation skills and join the elder class, when those students present their thesis projects. In order to enable the students to write their own theses, aspects of scientific writing are covered in a workshop. At the end of the seminar, the younger class joins the elder one for the graduation ceremony of the elder class.

Module “Advanced Therapies and Integrated Concepts”

This module is composed of the courses on clinical oncology as well as one that covers entity-overarching aspects of cancer patient care.

The two courses on clinical oncology cover the epidemiology, etiology, diagnostics, and multidisciplinary therapy of breast and gynecological cancers, urogenital cancers, cancers of the gastrointestinal tract, lung cancers, head and neck cancers, sarcomas, melanoma, cancers of the nervous system, cancers of unknown primary, HIV-associated malignancies, and tumors of the hematopoietic and lymphoid tissues as well as pediatric tumors. This intense agenda is supplemented by the course “Integrated Therapeutic Concepts,” which addresses palliative care, pain therapy, evidence-based complementary therapy, psycho-oncology, and communication and counseling.

The hard work on this module is compensated by the overwhelming experience of being part of the ESO (European Southern Observatory)/ESMO master class in clinical oncology. Before joining this live event, our students take their module examination and follow the five-day immersion in clinical oncology with European leaders and many master class participants from other countries. An essential part of this master class has been the training in difficult communication scenarios with professional actors and the instructive feedback together with the individual case presentations by the master class participants. This event is also a good bonding experience for each one of the participating classes. The “Ulm group” is frequently perceived as an entity and less as individuals. For the students, this learning and socializing experience is another highlight of their studies.

Module “Management”

The last online module of this curriculum consists of the courses “Business Basics,” “Health-Care System,” “Management of Entities and Processes,” and “Quality Control.”

The first course introduces concepts of business administration to the health-care professionals. Apart from managerial concepts and financial aspects, modern concepts of good governance are introduced, focusing on the needs of our learners. Next, a comparative assessment of health-care systems lines out different aspects of health-care organization in different countries and their benefits and disadvantages for patients. Using the German social security system as an example, decision-making in this system and cash flows are highlighted. “Management of Entities and Processes” contains lectures on the overarching concepts of WHO’s vision on cancer care, national cancer control plans (NCCPs), certification of tumor centers; management of practices, hospitals, and telemedicine; and ways on how to optimize clinical pathways. The course on quality control addresses individual points that need to be adjusted for proper quality control and improvement of cancer care including change management.

As usual, students take their module examination before exploring certain managerial aspects further. This comprises decision-making on the prices of cancer drugs, negotiation training, and a workshop on the optimization of clinical pathways. Being now the elder class, the students meet the younger class for the first time and network.

Summer School “Future Perspectives”

The second part of the last attendance seminar is the most exciting one because all students of the elder class present the status of their master’s thesis projects to three different groups, their supervisors, their peers, and the younger class. These presentations take place at the Reisensburg castle, a scientific meeting venue of Ulm University. In an intense exchange, data and concepts are being discussed, and suggestions for improvement are being made by supervisors and students alike. Personally, I like this part of the last seminar best, because the science is the most appealing part to me, and I observe the growth each and every student made during the course of their studies. This is also the moment, where supervisors and students engage in conversations as peers—as one would expect from learners achieving the next step and mentors accepting their mentees in their circle. It is then that everyone in the class is supported by all the students not presenting, and it forms a moving personal experience of having grown as a group, as a person, as a scientist, and as an expert.

The younger class is oftentimes a little bit intimidated by flawless presentations of their elders. This helps to encourage the youngsters to pursue their own thesis projects dutifully and knowingly. Most of all, it helps to identify all people present whom to network with on certain aspects of patient care or basic research, and this is an inherent feature of this study program.

In line with this are the graduation on the evening of the joint thesis presentations and the seminar on future perspectives, where we reflect together on aspects of improving cancer care in our own environment.

Master’s Theses

The theses are the most feared part of this study program because they demand a certain level of self-organization, networking, and, of course, scientific work. If students do not have direct patient contact, I strongly encourage them to perform a systematic review on a clinically meaningful question. The systematic reviews should be covering topics that are of interest to the students, but sometimes, a supervisor may have ideas for a thesis project, too. The other appeal of the systematic reviews is that they can be performed everywhere in the world, no matter the own resources. This introduces an aspect of fairness and equality. As long as all parties agree, this will move into the correct direction.

The educational achievement of the completed thesis equals 15 ECTS or a workload of about 450 h. This means that the work must be planned well in advance. Successful completion of the thesis means also that the student is willing to engage in a scientific discussion with the supervisor and vice versa. Even though this is usually the case, there are exceptions on both sides, which may result in a lower satisfaction on either side. Again, communication is key to success as is applied to project management and sometimes escalation.

In many countries, producing an own scientific work is not mandatory to graduate from medical school or its equivalent. Considering the ever-increasing new evidence and the need for critical appraisal of the published literature and ideally distilling the essence of a paper become essential tools for a physician to guide a patient through their cancer journey without harming them. Therefore, I think that unless somebody has access to a larger dataset, the skillset acquired while performing a systematic review is suited best to provide the best possible care for the patients, also in LMICs.

COVID-19-Related Adjustments

As a blended learning study program, we have only little in-person interaction with our students. The highlight of the year is usually the summer seminar at the Reisensburg castle near Günzburg, a secluded venue that enables scientific exchange and networking.

Due to the pandemic, this highlight of the year, together with the originally planned ten-year anniversary alumni meeting, had to be conducted virtually. Also, the ESO-ESMO master class 2020 had to be canceled. All seminars were organized to be conducted virtually, but we realized that sitting in front of a computer can be extremely draining when forced for longer periods. Our communication and negotiation trainers adjusted; our lecturers on pathology, health economic assessments, and evidence-based pathology adjusted; and the virtual format became the new “normal.” Also, the workshop on molecular diagnostics was conducted online, and we had the impression that the focus was more toward the explanations than the surroundings making learning enjoyable, too.

In our curriculum, we strive to make learning more palatable by offering more interactions between the seminars. Our psycho-oncologists have devised an entire new training set for patient-centered communication, and this was conducted online—in line with the new “normal” many of our students face during this pandemic.

Benefits for the University

I have asked above whether there is a benefit for the university in running this study program. My answer to this question will always be a resolute “yes.”

In offering this study program to participants from all over the world, the university opens its doors to highly educated and ambitious professionals pursuing the goal of improving cancer care in their personal environment. The university shares the expertise of its lecturers but gains also the reputation when these professionals succeed in their settings. Also, the internationalization, one of the developmental aims of the university, is gradually accomplished. You might ask how this may be the case with this small number of students. The point is that all people involved in the processes linked to this study program hone their skillset for internationality and welcoming diversity and serve as little nuclei of excellence wherever they are.

The study program by itself is worldwide unique. Other study programs exist in the field on basic research into oncology or more clinically oriented, but they are not the same, with a zooming-out perspective of oncology worldwide.

Together with our collaboration partner ESO, we have managed a knowledge transfer by establishing other postgraduate continuing education programs, the Certificate of Competence in Lymphoma and the Certificate of Competence in Breast Cancer.

Based on interactions in this study program, currently two grant applications were deposited. One focuses on improving health care in sub-Saharan Africa by means of vaccination; the other one focuses on improving teaching of evidence-based pathology. The latter would once more prove the expertise of Ulm University in running a postgraduate education for learners interested in improving oncology.

Quality Management and Further Plans

Our quality management is extensive, and many other programs might get along with less. However, we have more than 150 lecturers from all over the world, and we think that they can adapt their lectures to the needs of our students only when they know what is needed by the learners. We therefore encourage our students to give us feedback on every lecture they follow. This means that we collect their feedback and report it back to the lecturers and our superiors. Internally, we attribute medals (gold, silver, bronze) according to the rating within each module. In our feedback letter to each of the lecturers, we communicate the assessment by the students as well as our rating with differing degrees of emergency for renewal, also depending on the previous update. In my function as scientific director, I also follow recent developments and major communications from international meetings and major printed publications. I assess the feedback also with regard to the didactics employed by the lecturer, and I make detailed suggestions for didactic improvement. The major work therefore is updating the lectures according to newly generated knowledge in the basic sciences, new clinical evidence, new legislation, new behavioral aspects, and didactical refinements. This keeps all of us busy.

Our study program was first fully accredited according to the Bologna criteria in 2012, and it was reaccredited in 2018. This accreditation means that the educational achievement, the 60 ECTS, is fully transferable everywhere in Europe and all other countries that recognize the ECTS.

Taking the ten-year anniversary of the study program as a starting point, the inward and outward communication was majorly overhauled. Instead of a generic person, the face of the study program is now a real student carrying her experience with the study program as a message. Content-wise, the learning platform was updated and received a new “look-and-feel” that makes working with the platform easier, everything now optimized for mobile devices like tablet computers. The latter had only been introduced to the market at the time of the start of the study program and are now widely available and in use.

Starting in autumn 2021, interested parties may attend single module to educate themselves further. Among German, Austrian, and Swiss physicians, there was particular interest in the contents of the modules “Interdisciplinary Oncology” and “Advanced Therapies and Integrated Concepts” while claiming that busy schedules prevented many oncologists from engaging in the study program. The Medical Faculty and the Senate of Ulm University have therefore decided to open these modules so as to allow busy physicians to study particular aspects related to their everyday work. This shall serve also the purpose to further educate the workforce without forcing them to pursue the entire curriculum for better serving their patients while preventing burnout.

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Acknowledgments

The Advanced Oncology study program of Ulm University was funded by a grant of the Ministry of Science and Education of the Federal State of Baden-Württemberg. It would be impossible to run this program without the dedication of its over 150 lecturers as well as the previous and current core teams. ESO has accommodated our students for the ESO/ESMO master classes in clinical oncology, and we are grateful for this generosity.

Over the years, students were supported with scholarships from ESO, the Ruth and Adolf Merckle endowment fund of Ulm University, the Wieland Bildungswerk, and the Robert Bosch Foundation, an unconditional educational grant by Pfizer and the German Academic Exchange Service (DAAD).

I am grateful to everyone involved in running this program smoothly, to the core Advanced Oncology team, to all of our students, and most of all to my genetic and chosen families for their unwavering support.

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Schmidt-Straßburger, U. (2022). Blended Learning for Oncologists and Their Colleagues. In: Schmidt-Straßburger, U. (eds) Improving Oncology Worldwide. Sustainable Development Goals Series. Springer, Cham. https://doi.org/10.1007/978-3-030-96053-7_2

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