As an LMIC, Egypt has several barriers to providing high-quality professional education (Frenk et al. 2010). In the next section, we are going to highlight the most prominent challenges that we face at AS clinical oncology department as an example of oncology departments in university hospitals in Egypt.
Clinical Oncology Curriculum
Clinical oncologists are uncommon in developed countries (apart from the UK) but are the main providers of the service in many LMICs (Popescu et al. 2013). In the past two decades, knowledge has increased rapidly in both radiation oncology and medical oncology specialties, and this makes achieving the necessary competencies in both fields simultaneously very challenging (Sarin 2015). Another problem is that clinical oncologists find it easier to practice the use of systemic therapy than in radiation oncology thereby decreasing in the number of highly qualified radiation oncologists.
Duration of Clinical Oncology Program
Compared to the UK and US programs, the duration of our program is shorter which leads to deficits in training in important parts like research, leadership, communication, and managerial skills. This is also reflected on shortening of other parts in the curriculum as molecular biology and palliative care and spending most of the training time on treating patients with solid tumors.
Establishing competency-based radiation oncology programs in LMICs is hindered by a lack of resources such as state-of-the-art radiotherapy machines, highly qualified radiation oncologists, and supporting staff (Khader et al. 2020). At the AS clinical oncology department, we have two linear accelerators (one of them is volumetric modulated arc therapy), a CT simulator and an eclipse planning system (with five stations). There is no brachytherapy machine as of this date (due to be launched in April 2021). This infrastructure makes training approximately 15 candidates at different educational stages at a time challenging. We have around 20–25 monthly cases treated by intensity-modulated radiotherapy (IMRT), while the majority of patients receive three-dimensional conformal radiotherapy.
Systemic therapy at the department is sponsored by the Egyptian Ministry of Health (MOH). As other university hospitals and as a country with limited resources, many drugs—especially targeted and immunotherapy—are not covered. These drugs are available in the private sector and some of the health insurance-run hospitals. The safe use of these drugs and management of their side effects constitute an essential part of the clinical oncology training. The present situation makes parts of the curriculum only theoretical with regard to clinical application and thereby incomplete.
Supervision of Trainees
Lack of a structured workplace-based assessment (WPBA) is a very serious problem of the program. This is due to a combination of factors such as limited time of supervisors, lack of faculty training, and resistance of trainees.
Busy Hospital Environment
Egypt has the third largest population in Africa (> 100,000,000) and that makes public and university hospitals very crowded and busy with high volumes of patients and a limited number of supporting staff. At the AS clinical oncology department, we have around 200–250 visiting patients every day. As the system is very hierarchical, trainees are burdened with most of the work, which makes training and feedback very difficult.
Burnout and the inability to have a healthy work-life balance are the most serious challenges in our working environment. According to a recently published survey study at the AS clinical oncology department, 72% of participants (52 clinical oncologists) had burnout on the emotional exhaustion (EE) scale, 49% on the depersonalization (DP) scale, and 38% on the personal accomplishment (PA) scale (Ghali et al. 2019).
Lack of Research Opportunities
Limited budgets for research together with time constraints and lack of a reasonable number of international clinical trials at the department make trainees lack the opportunity to publish in high-impact specialized medical journals.
Our current assessment system is a pass-fail system (at 60%) and summative. It enforces focusing on knowledge rather than skills and lacks the very important part of “feedback.” Candidates have one final exam at the end of their training. Lack of frequent formative assessment is a serious problem with the current program as it makes the continuous professional development at this early career stage less transparent and less encouraging.