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Fulfilling the Potential of Cancer Prevention and Early Detection (2003)

Chapter: 8. Professional Education and Training

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Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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8
Professional Education and Training

Health care providers appear to be falling short ofexpectations that they counsel their patients regarding smoking, diet, and exercise and offer recommended screening tests to detect cancer early (see Chapters 4 and 6). According to recent studies, for example, less than half of adults who smoke cigarettes report that their physician inquired about smoking at their last visit, and among women eligible for breast cancer screening, roughly 20 to 30 percent report that they did not receive advice to have a mammogram. Improving professional education and training would seem an obvious remedy to this lack of counseling and screening advice, but evidence suggests that although improved education and training are necessary, these improvements by themselves are not sufficient to improve practice. Instead, education and training need to be coupled with other interventions so that practitioners are supported in their efforts with office systems that prompt them to adhere to guidelines, adequate reimbursement for behavioral interventions and screening services, and quality assurance systems that instill accountability. Enhancing professional education and training nevertheless remains one of the essential ingredients of a package of reforms needed to achieve national goals for cancer prevention and early detection set forth in Healthy People 2010 (US DHHS and Office of Disease Prevention and Health Promotion, 2000). Providers have recognized their limitations in this area and generally express interest in furthering their training (Block et al., 2000; Costanza et al., 1993).

This chapter begins with a discussion of the challenges of providing professional education and training; assesses the status of education and training with a focus on physicians, nurses, and dentists; and concludes

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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with a review of federal and private funding resources available to support education and training efforts.

CHALLENGES OF PROVIDING PROFESSIONAL EDUCATION AND TRAINING

Who Should Be Trained?

The education and training of health care providers occur on dual fronts, each of which has a unique set of challenges. First, those in training must be exposed to course work and clinical experience that reflect current evidence-based guidelines for cancer prevention and early detection interventions. Although updating of curricula would at first appear to be straightforward, such changes can be very difficult to make because of the competing demands among the various medical disciplines, each vying for the limited training time available. The second, and perhaps more daunting charge is providing continuing education to practitioners who are already trained but who have deficits in prevention education. As of 1997, most physicians (55 percent) had graduated from medical school before 1980 (American Medical Association, 1999), long before the publication of the U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services in 1989 and the availability of comprehensive smoking cessation guidelines.

In 1999 the United States had an estimated 9 million health care practitioners and health care technical and support staff (Bureau of Labor Statistics, http://stats.bls.gov), but this number does not capture fully those who may need to be trained in cancer prevention and early detection. Health plan managers not directly involved in hands-on care may need information on cancer screening guidelines to assess a proposed quality improvement program, and insurance company analysts may need up-to-date information on the costs and benefits of smoking cessation interventions to accurately price their package of benefits. Likewise, administrators who establish curriculum guidelines for public school systems and health educators who work in community-based social services settings may all require cancer-related education and training. Although this chapter recognizes the diversity of needs for education and training, the focus is on the education and training needs of direct providers of ambulatory health care services.

Among direct health care providers, answers to the questions of who should be trained and how they should be trained depend in part on who has regular contact with patients and the environment of contemporary practice. Where do individuals go for their routine or preventive care? In 1998, the vast majority of individuals relied on doctor’s offices and health maintenance organizations (69.7 percent) and clinics or health centers (15.6 percent) for

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

their care. Clearly, efforts to improve cancer prevention and early detection practices will have to focus on these ambulatory care settings.

Assessments of whom to train also require answers to questions about the number of providers who need to be trained and the appropriate roles for which physician and nonphysician providers of prevention services need to be prepared. The specter of a lack of provider capacity has arisen as the large baby boom cohort ages and falls into the age groups for whom regular screening is recommended. The need for qualified mammography providers, for example, will likely increase as the population ages and as more providers and women adopt screening recommendations. The number of women eligible for breast cancer screening is expected to increase by 46 percent from 2000 to 2020 (U.S. Census middle projections, www.census.gov/population/projections). The 2001 Institute of Medicine (IOM, 2001b) report Mammography and Beyond cites anecdotal reports that inadequate numbers of mammographers and mammography technologists are being trained to fill current and future needs, but it also notes that good data to support such claims are lacking. The IOM committee that prepared that report recommended that a study be conducted to assess provider supply.

Likewise, the demand for colorectal cancer screening could easily outpace the number of physicians trained to conduct the tests recommended in colorectal cancer screening guidelines (e.g., sigmoidoscopy and colonoscopy) if gains in the rate of acceptance of such screening tests are coupled with the aging of the baby boom cohort (Schoenfeld, 1999). Increased demand for tests could renew long-standing calls for greater involvement of nonphysician providers in screening programs. However, despite evidence suggesting that appropriately trained nurses can perform flexible sigmoidoscopy with the same degrees of accuracy and safety as physicians (Fletcher and Farraye, 1999; Maule, 1994; Schoenfeld, 1999; Schoenfeld et al., 1999), they have not uniformly been accepted as providers within health care systems (Floch, 1999). Nevertheless, several professional societies (e.g., the American Society for Gastrointestinal Endoscopy and the British Society of Gastroenterology) have endorsed the performance of flexible sigmoidoscopy by nurses, but 16 of 50 U.S. state boards of nursing expressly prohibit registered nurses from performing screening flexible sigmoidoscopy (Cash et al., 1999).1 In 1996 the U.S. Preventive Services Task Force included a recommendation that flexible sigmoidoscopy be used to screen asymptomatic adults age 50 and older, and since 1998 Medicare has provided reimbursement for screening flexible sigmoidoscopy, but only physicians are

1  

Fifteen of 16 of these states allow nurse practitioners, but not registered nurses, to perform screening flexible sigmoidoscopy (Cash, 1999). Among U.S. institutions with gastroenterology fellowship programs, 15 percent (24 of 164 programs) were using paramedical personnel to perform flexible sigmoidoscopy (Cash, 1999).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

reimbursed “to ensure that [the procedures] are performed as safely and accurately as possible” (Health Care Financing Administration, 1997).2

The demand for personnel to provide smoking cessation interventions should be very high given that an estimated one-quarter of the U.S. adult population smokes cigarettes. Physicians are important providers of smoking cessation interventions, but nonphysician personnel can be as effective as physicians as providers of interventions aimed at ending tobacco dependence and can do so at lower cost (US DHHS, 2000a). According to smoking cessation guidelines, multiple types of clinicians are effective and should be used. Well-established evidence-based guidelines are available for providers, but too few smokers are getting appropriate counseling and referrals to smoking cessation programs, according to assessments of provider practice (see Chapter 4). In general, less than half of smokers report on surveys that they received advice to quit smoking at their last physician visit (Doescher and Saver, 2000; Jaen et al., 1997). Smoking cessation guidelines include recommendations for the prescription of medications for certain individuals, but limitations on nonphysician practitioners’ authority in this area could limit their role as primary providers of smoking cessation interventions. Most state practice laws limit prescriptive authority to physicians, dentists, and certain advanced practice providers such as nurse practitioners.3

One counseling strategy would be to have a medical clinician or a health care clinician deliver messages about health risks and benefits and deliver pharmacotherapy (e.g., bupropion or a nicotine patch) and to have nonmedical clinicians deliver additional psychosocial or behavioral interventions (US DHHS, 2000a). Some have advocated a stepped care approach for the treatment of nicotine dependence in which more intensive services are targeted to those with higher degrees of addiction or with comorbid conditions such as mental illness (Abrams, 1993). According to this model, a highly motivated smoker might require minimal assistance and be effectively treated with a brief intervention from a physician, nurse, or other health care provider within the course of a routine health care contact. A heavy smoker discouraged by a history of poor success with

2  

Although Health Care Financing Administration guidelines prohibit Medicare reimbursement of professional fees to nonphysicians for the performance of screening flexible sigmoidoscopy (and many national insurance agencies follow these guidelines), no policy prohibits the reimbursement of a facility fee when flexible sigmoidoscopy is performed by nonphysicians (when screening flexible sigmoidoscopy is performed in an outpatient setting, however, a facility fee is reimbursed only if a biopsy is performed) (Schoenfeld, 1999).

3  

All states provide some authority for nurse practitioners to prescribe noncontrolled substances such as those recommended in smoking cessation guidelines (e.g., certain nicotine replacement products or bupropion). In most states, prescriptive authority is granted only while the nurse practitioner is working in collaboration with a physician (National Conference of State Legislatures, American Nursing Association, www.ncsl.org/programs/health/Nurseaut.htm).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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attempts at quitting might require referral to more intensive specialized treatment with follow-up. The tobacco user who is clinically depressed or who is also alcohol- or drug-dependent might best be served by a licensed mental health professional or an alcohol or drug addiction professional (Pbert et al., 2000). In terms of program intensity, evidence suggests that the counseling session length should be longer than 10 minutes, there should be four or more sessions, and the total contact time should be longer than 30 minutes (US DHHS, 2000a). Given evidence that current ambulatory care practices do not accommodate these recommendations very well (e.g., visits are short and contacts with nurses are limited), there appear to be opportunities to develop innovative models that integrate nonphysician providers and specialized referral services into office-based practices.

What Needs to Be Learned?

Perhaps the most important component of any education and training program is a clear statement of what is expected of the student following completion of the course of study. A set of expectations of health care providers regarding cancer prevention and early detection has been set forth in the objectives of Healthy People 2010 (US DHHS and Office of Disease Prevention and Health Promotion, 2000) (Box 8.1). Having a clear set of objectives provides useful guidance to educators regarding the didactic materials that need be covered in the curriculum and the clinical experiences that are needed to ensure competency.

BOX 8.1 Selected Healthy People 2010 Cancer Objectives

Behavioral Interventions

  • Increase the proportion of physicians and dentists who counsel their at-risk patients about smoking and tobacco use cessation, physical activity, and cancer screening to at least 85 percent.

Cancer Screening

  • Increase the proportion of women age 18 and older who received a Pap test within the preceding 3 years to 90 percent.

  • Increase the proportion of adults age 50 and older who have received a fecal occult blood test within the preceding 2 years to 50 percent.

  • Increase the proportion of adults age 50 and older who have ever received a sigmoidoscopy to 50 percent.

  • Increase the proportion of women age 40 and older w ho have received a mammogram within the preceding 2 years to 70 percent.

SOURCE: US DHHS and Office of Disease Prevention and Health Promotion (2000).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

This chapter focuses on the education and training needs of ambulatory care providers for whom knowledge in a variety of areas and a diverse set of skills must be acquired. The knowledge and skills needed for cancer prevention and early detection span population science (e.g., epidemiology and biostatistics), behavioral science (e.g., psychology and counseling), and basic science (e.g., pathology and molecular biology). The effective practice of cancer prevention and early detection can also depend on knowledge of and patient referral to community-based resources and support services. The disciplines of cancer prevention and early detection, like other areas of medicine, are subject to innovation, new technology, changing and conflicting guidelines, and controversy surrounding what constitutes best practice. Being able to provide good counsel to patients requires staying abreast of developments and knowing where to go for sources of credible information. Furthermore, education and training programs need to promote evidence-based practices and impart evaluative skills to students so that they can judge when to incorporate new interventions into their practices.

Although much of the counsel offered by providers of cancer prevention and early detection services can be prescriptive (e.g., advice to quit smoking), much of it cannot be because not enough is known about the benefits (and potential harms) of interventions. Men considering prostate-specific antigen testing to screen for prostate cancer, for example, should be informed of the relative benefits and harms related to screening and subsequent follow-up procedures and outcomes. Similarly, patient values and preferences should be considered along with information about the risk of cancer and the risk of testing to determine the most appropriate colorectal cancer screening method (Woolf, 2000a,b). Counseling patients about the relative risks and benefits of screening and eliciting information from patients regarding their concerns and values are time-consuming and require skill, however. Likewise, facilitation of a patient’s behavioral change by a health care provider is a complex process and involves a cycle of assessment, assistance, reiteration, and continuing support. Professional education and training in the areas of cancer prevention and early detection would be incomplete if counseling skills and familiarity with the challenges (and rewards) of behavioral interventions were not core parts of the curriculum and clinical training experience (Ockene et al., 1990).

There are glaring disparities in the rates of cancer morbidity and mortality between socioeconomic groups, insured and uninsured individuals, and certain racial and ethnic groups (see Chapter 1). Lack of health insurance coverage is a key predictor of lower rates of use of cancer screening tests, but other sociocultural factors may also be at play. In a nation of increasing diversity, health care providers must be trained to accommodate language differences in their practices and must be aware of cultural values and beliefs that might need to be addressed during discussions of cancer prevention and early detection.

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

Education and training programs aimed at health care providers need to emphasize evidence that systemwide approaches are most effective in promoting disease prevention and health promotion and that providers are an integral part of that system. Providers can develop integrated approaches that use community-based resources to extend the impacts of their messages delivered in the health care context. For example, an extensive array of community-based smoking cessation programs (e.g., programs offered through the American Lung Association or the American Cancer Society) can supplement services provided in an office-based practice. Given the reality of time constraints in ambulatory care practice, referral to community-based specialists may be the most appropriate way to provide treatment services. Likewise, for patients who lack health insurance (or for patients who are underinsured), certain cancer screening services are available in community-based clinics at no cost or at a reduced fee (e.g., the Centers for Disease Control and Prevention’s [CDC’s] Breast and Cervical Cancer Early Detection Program).

Prevention services are most effectively integrated into ambulatory care when office systems are in place to remind providers of a patient’s smoking status or eligibility for cancer screening. Furthermore, efforts to improve rates of adherence to evidence-based guidelines increasingly include quality improvement models that inform practitioners of their performance relative to those of their peers or accepted standards (see Chapter 9). Education and training programs should include didactic and clinical experiences that incorporate these systems of accountability.

In summary, professional education and training programs focused on cancer prevention and early detection can be offered to a range of providers in a variety of settings. Some programs may be housed within an individual medical or dental school, some may be organized regionally under the auspices of a state comprehensive cancer plan, whereas others may be sponsored nationally by representatives of professional societies or a particular federal program. Wherever they are offered and however they are organized, professional education and training programs ideally would include the following key components:

  • a focus on established goals and objectives, such as those established as part of Healthy People 2010 (US DHHS and Office of Disease Prevention and Health Promotion, 2000);

  • an emphasis in the curriculum on evidence-based interventions and the interpretation of evidence in the context of population-based medicine;

  • interdisciplinary didactic material and training experiences spanning the disciplines of the basic, population, and behavioral sciences;

  • development of skills to integrate community-based resources into office practice;

  • training and experience in providing services to special populations;

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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  • continuing education to ensure maintenance of up-to-date knowledge and skills; and

  • experience with systems approaches to promote quality care and accountability.

STATUS OF PROFESSIONAL EDUCATION AND TRAINING

The previous section of this chapter explored in some detail the National Cancer Policy Board’s vision of who should be trained to provide cancer prevention and early detection services and what should be learned in education and training programs. This section examines how this ideal can be approached by reviewing the status of health promotion and disease prevention education and training in medical, nursing, and dental schools. Of note, at the time of this assessment there were few systematic reviews of curricula, texts and educational materials, training experiences, and continuing education opportunities related to cancer prevention and early detection.

Medical Schools

There is a general consensus that physicians are not adequately trained to deliver cancer prevention and control interventions (Brink et al., 1994; Costanza et al., 1993; Glanz et al., 1995; Kushner, 1995; Ockene, 1987; Ockene and Zapka, 1997, 2000; Ockene et al., 1996; Strecher et al., 1991). Practicing physicians themselves identify their lack of training and confidence as barriers to the delivery of cancer prevention and control interventions (Ashford et al., 2000; Becker and Janz, 1990; Berman et al., 1997; Brink et al., 1994; Costanza et al., 1993; Gilpin et al., 1993; Manley et al., 1992). This section of the report describes efforts to address shortcomings in both undergraduate and graduate medical school training and examines the availability of training opportunities in two areas, tobacco cessation and nutrition.

Undergraduate Medical Student Training

Attempts to improve the coverage of health promotion and disease prevention in the medical school curriculum have had a long history and have largely been led by professional organizations (Box 8.2).

As early as 1945, the American Association of Medical Colleges (AAMC) recommended that each medical school establish a department of preventive medicine (Association of American Medical Colleges, 1945). In a major report issued nearly 40 years later, an AAMC panel recommended that “the emphasis on preparing medical students to care for individuals

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

BOX 8.2 Professional Organizations with a Focus on Health Promotion and Disease Prevention

Association of American Medical Colleges

The Association of American Medical Colleges (AAMC) is a nonprofit association founded in 1876 to work for reform in medical education. AAMC represents the 125 accredited U.S. medical schools, 400 major teaching hospitals and health systems, 90 academic and professional societies representing nearly 100,000 faculty members, and the nation’s medical students and residents. The AAMC works with its members to set a national agenda for medical education, biomedical research, and health care. AAMC assists its members by providing services at the national level, services that facilitate the accomplishment of their missions (www.aamc.org/about/start.htm).

Association of Teachers of Preventive Medicine

The Association of Teachers of Preventive Medicine (ATPM), a national professional association, is dedicated to advancing health promotion and disease prevention in the education of physicians and other health professionals. ATPM publishes curriculum guidelines (e.g., Teaching Prevention Throughout the Curriculum: Multidisciplinary Perspectives on Enhancing Disease Prevention and Health Promotion in Undergraduate Medical Education (Association of Teachers of Preventive Medicine, 2000), directories of programs in public health and preventive medicine, and the American Journal of Preventive Medicine. ATPM is developing, in partnership with the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) and the Centers for Disease Control and Prevention, a series of distance learning modules for health care providers called Improving Provider Education on Federal Health Programs. The educational program is aimed at health care providers and administrators, particularly those who serve minority populations, to inform them about the range of clinical and prevention services and administrative requirements for Medicaid and the State Children’s Health Insurance Program.

American Association for Cancer Education

The American Association for Cancer Education (AACE), founded in 1947, provides a forum to address cancer education at the undergraduate, graduate, continuing professional, and paraprofessional levels. The association is involved in educational issues throughout the cancer continuum, from prevention, early detection, and treatment to rehabilitation. A group of AACE members participates in a cancer prevention education section. AACE’s membership of approximately 400 includes the faculties of schools of medicine, dentistry, osteopathy, education, pharmacy, nursing, public health, and social work. AACE encourages projects for the training of paramedical personnel and educational programs for the general public, populations at risk, and patients with cancer. AACE publishes the Journal of Cancer Education and the Cancer Education Newsletter.

American Society of Preventive Oncology

The American Society of Preventive Oncology (ASPO), a 25-year-old professional organization with roughly 400 members, aims to promote the exchange and dissemination of information relating to cancer prevention and early detection; to identify

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

and stimulate new research; and to support the implementation and evaluation of national, state, and local programs and policies (www.aspo.org, accessed December 13, 2000). Membership is largely from academic settings and is diverse, with representatives from anthropologists, communications specialists, biostatisticians, epidemiologists, medical oncologists, and psychologists. ASPO, in cooperation with the American Association for Cancer Research, publishes the journal Cancer Epidemiology, Biomarkers and Prevention.

SOURCES: http://rpci.med.buffalo.edu/aace/aacef1.html, accessed December 6, 2000; Judy Bowser, ASPO executive director, personal communication, December 13, 2000; www.atpm.org/education/IMPROVIN.htm, accessed January 3, 2001.

with acute illnesses ... be balanced by an equivalent emphasis on promoting health and preventing disease” (Muller, 1984, p. 6).

A panel of the Association of Teachers of Preventive Medicine (ATPM) proposed in 1989 minimum requirements for curricular content related to health promotion and disease prevention, including recommendations for course timing, duration, and sequencing during medical school. In 1990, another expert ATPM panel recommended incorporation of the Guide to Clinical Preventive Services (U.S. Preventive Services Task Force, 1989) into both the undergraduate and postgraduate medical education (Altekruse et al., 1991; Collins et al., 1991).

An effort to improve medical schools’ disease prevention and health promotion curricula and the ability to evaluate medical students’ knowledge of disease prevention and health promotion principles and their application was launched in 1994. The effort was called the Prevention Curriculum Assistance Program (PCAP) and was funded by ATPM and the federal government’s Health Resources and Services Administration (HRSA). Between 1997 and 1999 PCAP surveyed medical schools regarding their curricula and means of evaluation of students. A prevention self-assessment analysis inventory was created to allow comparison of existing curricula with recommended standards. The inventory covered four areas (Garr et al., 2000):

  1. clinical prevention services,

  2. quantitative methods,

  3. community dimensions of medical practice, and

  4. health services organization and delivery.

Virtually all (96 percent) of the responding programs expected medical students to be able to identify the age- and sex-specific recommendations

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

for screening tests, prevention counseling, immunizations, and chemoprophylaxis. Less than one-third of the programs (31 percent) were satisfied with the quality of the evaluations they were using to assess students’ abilities in clinical prevention services, and 41 percent of the programs expressed a desire to receive assistance with the design of their curricula or evaluation methods relating to clinical prevention services (Garr et al., 2000). With recognition that “evaluation drives learning,” recommendations on how best to evaluate the competence of medical students in prevention have been outlined (Blue et al., 2000).

In another recent development, AAMC established the Medical School Objectives project to set forth program-level learning objectives that medical school deans and faculties could use as guides in reviewing and then improving their medical student education programs. Among the educational objectives recommended by the AAMC Population Health Perspective Panel is that medical students be able to “incorporate principles of disease prevention and behavioral change appropriate for specific populations of patients within a community” (Association of American Medical Colleges, 1999, p. 139). Suggestions designed to facilitate the development of a curriculum in population health, which would logically include the principles and practice of cancer prevention and early detection, included the following:

  • Medical schools should develop an explicit list of mechanisms by which population health objectives are to be met.

  • Teaching faculty should be identified.

  • Liaisons should be formed with others who can help (e.g., the American Board of Preventive Medicine and Teachers of Preventive Medicine).

  • The AAMC Liaison Committee on Medical Education should require that schools show evidence that they have developed objectives, designed and delivered a curriculum, and tested students for their competencies in population health.

  • Competencies in population health should be tested in the examinations of the National Board of Medical Examiners.

The panel further suggested that AAMC take steps to facilitate and reinforce movement toward more effective teaching of population health by (Association of American Medical Colleges, 1999, p. 141):

  • clearly articulating to the medical school leadership and constituency the priority of ensuring instruction in and supporting a population health curriculum;

  • providing a clearinghouse of curricular materials and experts who can help schools develop their curricula and encouraging the development of an in-school infrastructure that links the functions of the schools of medicine

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

and public health, as well as those of the schools of nursing, pharmacy, and health services administration, in a way that creates interests and opportunities for teaching, research, and learning in population health;

  • including specific curricular elements, objectives, processes, and outcomes for population health on the annual AAMC curriculum survey and listing the schools that have developed a population health curriculum in the AAMC curriculum directory;

  • developing an explicit list of expectations of how teaching and learning at the undergraduate level should fit with postgraduate education programs; and

  • encouraging public and private funding agencies to balance biomedical research funding with that provided for health services and public health research.

An Inventory of Knowledge and Skills Relating to Disease Prevention and Health Promotion has been developed jointly by the Bureau of Health Professions of the Health Resources and Services Administration, the Association of Teachers of Preventive Medicine, and the Medical School Objectives Project of the Association of American Medical Colleges. In 1998, these groups developed a set of core competencies in preventive medicine for undergraduate medical education (Pomrehn et al., 2000) so that students could:

  • identify recommended clinical prevention services including screening tests (e.g., the Pap test and mammography) and prevention counseling (e.g., smoking cessation, dietary modification, and physical activity);

  • demonstrate the skills necessary to perform screening tests and conduct preventive counseling; and

  • understand the features of health systems (e.g., reminder systems for providers) that promote the integration of disease prevention interventions into clinical practices.

Emphasis was placed not only on teaching about prevention but also on providing opportunities to show students how to apply prevention interventions to patient care.

How do medical students view their training in disease prevention and health promotion? According to the Medical School Graduation Survey performed by AAMC, there has been a steady increase in the proportion of graduates reporting that an “adequate” amount of time in the curriculum is spent on health promotion and disease prevention, from 54 percent in 1993 to 76 percent in 1997 (Pomrehn et al., 2000).

There has also been a long history of critical evaluation of cancer education in medical school, although much of the focus has been on the curricula pertaining to cancer diagnosis and treatment rather than cancer

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

prevention and early detection. In the late 1970s, the National Cancer Institute (NCI) funded what is known as the Cancer Education Survey I. This comprehensive assessment involved an educational resources questionnaire, a faculty and curriculum questionnaire, a student questionnaire, and site visits to 44 medical schools. Findings from this effort led to three recommendations (Bakemeier et al., 1992):

  1. cancer education grant programs needed to be continued and expanded,

  2. cancer education objectives should be defined, preferably on a nationwide basis, and

  3. improved evaluation mechanisms should be developed and applied by all schools in a program of internal self-assessment of their cancer education programs.

After publication of the results of Cancer Education Survey I in 1981, the American Association for Cancer Education (AACE) in 1986 published Cancer Education Objectives for Medical Schools (Bakemeier and Edwards, 1986) and guidance on how to apply them (Bakemeier et al., 1992). A few years later, in 1989, AACE published nutrition cancer education objectives (Bakemeier et al., 1989). A follow-up survey, Cancer Education Survey II, was conducted in 1989–1990 and was funded by the American Cancer Society (Bakemeier et al., 1992; Gallagher et al., 1992; O’Donnell et al., 1992). Eight recommendations emanated from the second survey (Gallagher et al., 1992, pp. 97–101):

  1. Cancer educators should receive training in the process of instructional planning.

  2. The Cancer Education Objectives developed by AACE should be evaluated for currency and adaptability by a wide range of cancer teaching programs (very few faculty surveyed used the teaching objectives).

  3. Formal studies are needed to clarify the conditions under which formal written cancer education objectives enhance the teaching and learning process.

  4. Each institution should examine the appropriateness of the teaching method(s) being used to achieve each of its cancer education objectives.

  5. High-quality, learning-validated, computer-assisted instruction programs that are useable in a wide range of institutions and settings should be developed.

  6. Formal studies on how best to use computer-assisted instruction should be undertaken and reported in the cancer education literature.

  7. Model demonstration teaching programs that exemplify effective cancer teaching practices in outpatient care settings should be designed and

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

formally studied. Successful programs should be described and disseminated in the cancer education literature.

  1. Model demonstration teaching programs that exemplify effective cancer education instruction and that use cancer tumor registries should be designed and formally studied. Successful educational practices should be described and disseminated in the cancer education literature.

Recurring themes in evaluations of both health promotion and disease prevention curricula and cancer education curricula in medical schools are the need to identify educational objectives, the need to ensure resources and mechanisms to attain objectives, and the need to encourage change through dissemination activities (e.g., of best practices) and accountability.

It is difficult to judge the extent to which cancer prevention and early detection are addressed in medical schools without a careful review of detailed course outlines and clinical training opportunities. More cursory reviews of medical school curricula suggest that cancer prevention education is not prominently mentioned in the available descriptive materials. For example, in a recent assessment based on literature reviews, a survey of medical school websites, and contacts with listservs, only 15 medical schools had explicit cancer prevention offerings (Herl et al., 1999). Similarly, a review of the curricular content listed in the AAMC curriculum database, CURRMIT, revealed relatively few offerings (Johnson L, Association of American Medical Colleges, personal communication to M. Hewitt, 2001). Surveys of students enrolled in some medical schools indicate that cancer prevention is getting too little emphasis. In a recent assessment conducted at Boston University Medical School, for example, more than half of all the students surveyed indicated that cancer prevention was given too little emphasis in their curriculum (Geller et al., 1999). Some medical schools have integrated prevention-related counseling skills into their curricula. At the University of Massachusetts, for example, medical students are exposed to behavioral medicine and risk factor counseling skills at multiple points in the curriculum (Ockene et al., 1990). Although few comprehensive assessments of cancer prevention and early detection education and training in medical school are available, focused reviews of training in smoking cessation and nutrition have been conducted.

Training in Smoking Cessation in Undergraduate Medical Education

According to Cancer Education Survey II conducted in 1989–1990, only a third of medical schools taught smoking prevention and cessation methods in lectures, and less than a third of schools provided instruction on these topics by another mode (Chamberlain et al., 1992; Gallagher et al., 1992). An expert panel convened by NCI in 1992 recommended that by 1995 smoking cessation and prevention interventions be mandatory com-

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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ponents of undergraduate medical education (Fiore et al., 1994). According to the NCI panel, curricula that teach smoking and tobacco use cessation interventions contain 12 essential elements. These are outlined in Box 8.3.

An assessment of the U.S. undergraduate medical school curricula in 1996–1997 revealed that 55 percent of medical schools had incorporated the six recommended basic science content areas into their basic science curricula but that only 4 percent of schools included the 6 recommended clinical science content areas into their clinical science curricula. Most medical schools (69 percent) did not require clinical training in smoking cessation techniques, but 23 percent offered additional experience as an elective course. Investigators recommended that a model core smoking and tobacco use cessation curriculum be developed and implemented in all U.S. medical schools (Ferry et al., 1999). The importance of this recommendation is further emphasized by the fact that some assessments suggest that medical students have positive attitudes toward health promotion (Bellas et al., 2000) and that when they are provided training they can achieve high levels of confidence in their ability to help patients quit smoking (Zapka et al., 2000a).

Educational interventions during formal medical training, in particular, opportunities for hands-on practice, improve trainees’ ability to deliver smoking cessation interventions and in some cases increase smoking cessation rates, according to some evaluations of these interventions. Significant

BOX 8.3 Recommended Content Areas for a Smoking and Tobacco Use Cessation Intervention Curriculum

Basic Science

  • Cancer risk from smoking and tobacco use

  • Health effects (smoking- and tobacco-related diseases)

  • Effects of passive smoking

  • Cigarette smoke contents (nicotine, tar, carbon monoxide)

  • Nicotine withdrawal symptoms

  • High-risk groups with the most difficulty quitting (e.g., teens, pregnant women, and individuals with psychiatric disorders)

Clinical Science

  • Clinical interventions (five A’s: anticipate, ask, advise, assist, and arrange)

  • Relapse prevention

  • Pharmacological agents (nicotine replacement or antidepressant therapy)

  • Smoking cessation techniques in artificial setting with no patients

  • Smoking cessation techniques in clinical setting with patients

  • Smoking cessation techniques in clinical setting with patients and evaluation of performance

SOURCE: Ferry et al. (1999).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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improvements were found, for example, in family practice and internal medicine residents’ knowledge of smoking risks, perception that they could affect patients’ behavior, and counseling skills after a 3-hour training program that showed residents how to offer brief, patient-centered smoking cessation counseling (Ockene et al., 1988). After implementation of the program, patients’ smoking cessation rates were shown to increase significantly. Allen and colleagues (1990) built on this work by testing a 2-hour workshop for second-year medical students. Trained students reported greater confidence in their ability to help patients stop smoking and performed better on an objective structured clinical examination than students in a control group. The investigators concluded that the use of specific instruction and opportunities for practice were important for students to successfully translate the smoking cessation skills knowledge into clinical practice (Allen et al., 1990; Ockene et al., 1988). The use of simulated patients has also been shown to improve the smoking cessation skills of medical students (Coultas et al., 1994). One randomized study of 261 internal medicine, family practice, and pediatric residents showed that educational interventions improved trainees’ behavior but did not lead to subsequent changes in smoking behavior among patients seen by the trainees (Strecher et al., 1991).

Nutrition Education in Undergraduate Medical Education

The public sees physicians as the prime source of information on nutrition, so physicians have an obligation to be prepared to encourage healthy dietary practices and to refer patients to nutrition specialists when indicated (Levin, 1999). Dietary counseling in the context of primary care is needed not only to reduce the risk of cancer but also to counter the obesity epidemic in the United States and to reduce the risk of a number of chronic conditions associated with poor dietary practices, such as heart disease and diabetes. As with smoking cessation interventions, physicians can be effective agents of dietary change for patients when training in nutrition counseling is coupled with a supportive office environment (Ockene et al., 1996, 1999). Health care providers do not appear to be addressing dietary problems among the patients in their practices, however. In a 1996 survey, for example, less than half (42 percent) of obese individuals reported that their health care professional had advised them to lose weight during a visit for routine care made within the last year (Galuska et al., 1999).

A 1985 National Academy of Sciences survey of nutrition education in U.S. medical schools found that only 22 percent of medical schools had a clearly defined course in nutrition and 50 percent of the medical schools taught less than 20 hours of nutrition-related materials in their required curricula (National Research Council, 1985). One obstacle to nutrition literacy among physicians is the limited number of nutrition specialists on

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
×

medical school faculties who can effectively advocate for change in medical school and residency curricula and who can serve as role models for the incorporation of nutrition counseling into patient care (Intersociety Professional Nutrition Education Consortium, 1998).

Considerable grant support to improve nutrition education in medical schools has led to some increased attention to nutrition in the medical school curriculum. In particular, NCI R25 training education grants have funded nutrition education development and innovations at selected medical schools since the late 1980s:

  • The University of Nevada School of Medicine developed a required 20-hour freshman course, Medical Nutrition; elective courses in nutrition for juniors and seniors; and for seniors, an assignment in nutrition and cancer during a rural rotation with faculty preceptors. Funding also supported integration of nutrition education into the basic science courses, patient care courses, and specialty clerkships (Ashley et al., 2000).

  • The University of North Carolina at Chapel Hill developed an interactive CD-ROM that teaches nutrition and nutritional biochemistry to medical students. By 1999 it had been distributed to all U.S. medical schools and was in use in 76 of them (Plaisted et al., 2000).

  • The University of California, Los Angeles, School of Medicine developed a coordinated, vertically integrated, 2-year nutrition education curriculum to address identified proficiencies in nutrition education (Hodgson et al., 2000).

  • The University of Arizona College of Medicine assessed its nutrition education curriculum, developed and evaluated specific course content, and moved toward comprehensive prevention-based nutrition education (Thomson et al., 2000).

  • The University of Colorado Health Sciences Center developed a nutrition elective, Nutrition and Cancer, for students of the health professions and a section on nutrition was incorporated into the biochemistry course (Bakemeier, 2000).

  • The University of Alabama at Birmingham supported predoctoral and postdoctoral trainees to address the shortage of health care professionals trained in the nutritional aspects of cancer prevention (Heimburger et al., 2000).

  • The New York Academy of Medicine developed a minifellowship in clinical nutrition for primary care physicians to improve the availability of faculty to serve as role models and clinical preceptors for medical students (Deen et al., 2000).

Despite these and other investments, evidence suggests continued deficits in medical school nutrition education. For example, only 23 percent of medical school graduates surveyed by AAMC in 2000 reported that they

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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had received adequate experience in clinical nutrition, but perceptions of training varied by clinical situation. Nearly half of the stu1dents surveyed (49 percent) believed that they were adequately trained to assess patients with type II diabetes nutritionally, and 58 percent believed that they were adequately trained to assess patients with coronary heart disease. On the other hand, only 26 percent felt comfortable assessing obesity or undernutrition, and only 23 percent believed that preceptors with whom they had worked during their clerkships served as appropriate role models in their provision of clinical nutrition services (Lockwood et al., 2000). Methods that can be used to improve training in nutrition in medical school have been suggested and include the following: curriculum analysis, the use of computer-aided instruction modules, Internet Websites, case-based tutorial discussions, physician nutrition specialists and dietitians, administratively separate nutrition units, and observed structured clinical examinations, and faculty development (Lo, 2000).

Graduate Medical Education

Preventive medicine specialists often teach cancer prevention and early detection courses within medical schools or provide the needed leadership in state health departments to oversee population-based prevention programs. By one estimate, there were roughly 6,000 certified specialists in preventive medicine in 2000 (Lane et al., 2000), but these represent less than 1 percent of the total number of physicians in the United States (American Medical Association, 1999). The total number of residents training in primary care has remained relatively constant in recent years, but concerns have been raised about the adequacy of the supply of preventive medicine specialists. Some attribute the declines in the number of trainees to diminishing support for residency training through the government’s Title VII program (support provided by HRSA) (Lane et al., 2000). As of 1999, there were 88 certified programs in preventive medicine (an additional 6 internal medicine programs offered a subspecialty in preventive medicine) (http://www.ama-assn.org/cgi-bin/freida.cgi).

In some cases, special curricula have been developed to provide additional training in cancer prevention to residents in primary care programs. One such example is the Recommendations for Cancer Prevention program developed at the University of Texas M. D. Anderson Cancer Center. The curriculum consisted of a series of seven 1-hour presentations. A test of the curriculum among 21 primary care residents showed relatively poor knowledge about cancer prevention before the training program and modest gains in knowledge after the program (Chamberlain et al., 1995; Spitz et al., 1992).

According to one survey of primary care residents, 40 percent reported that the residency was preparing them to provide nutrition counseling and

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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education services, 79 percent reported that the residency should be preparing them to provide nutrition counseling and education services, and 65 percent planned to offer nutrition counseling and education services. Even though the residents rated nutrition counseling as important, they had only fair confidence in their ability to conduct it (Orleans et al., 1985; Rosen et al., 1984; Walsh et al., 1999; Wells et al., 1986).

Educational interventions targeted to medical residents have increased confidence in the ability to provide counseling and have increased counseling activity according to the few assessments that have been published. Most studies on improvements in the nutrition knowledge and counseling skills of medical residents have focused on cardiovascular disease or general health promotion. One study, for example, assessed 130 internal medicine residents to determine if an educational and prompting intervention improved dietary counseling practices (Evans et al., 1996). Residents participated in two 1-hour sessions to improve their skills and confidence in dietary counseling. The education materials included a contract for the patient and physician, a dietary assessment tool with matching dietary advice, a wallet card for the patient, a recipe book, and pamphlets. At the 10-month follow-up, residents reported increased confidence in providing dietary counseling.

A significant increase in dietary counseling (12 to 94 percent) by residents as measured by chart audit was achieved after implementation of a practice-based teaching model aimed at improving compliance with U.S. Preventive Services Task Force guidelines (Geiger et al., 1993; U.S. Preventive Services Task Force, 1996). In contrast, no significant change in self-reports of counseling for nutrition and diet modification was observed after an educational intervention that involved making patient education booklets available and participation in several grand rounds (Madlon-Kay et al., 1994).

According to one assessment, physicians had received little to no training in physical activity counseling, and most did not believe that they had the knowledge or the skills needed to effectively counsel their patients about physical activity (Scott et al., 1992). One intervention to change residents’ attitudes and behaviors about physical activity counseling led to improvements in physician confidence in physical activity counseling and self-reported counseling rates (over 3 months), but did not result in changes in physical activity levels among their patients with chronic diseases (Eckstrom et al., 1999). The residents were trained in two 2-hour workshops where they learned counseling skills specific to populations with chronic diseases, participated in a problem-solving session, and received educational handouts and information about community resources.

In another study, family practice residents randomly assigned to a group that was trained in approximately 15 minutes to give 2 to 3 minutes of exercise advice gave exercise advice to patients almost twice as often as

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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those in the control groups, and the patients who received the advice significantly increased their exercise durations but not their exercise frequencies (Lewis and Lynch, 1993). In addition to the advice, the residents in the experimental group distributed an educational handout and advised the patient that a staff member would call in 1 month. An educational handout on the patient’s chart prompted the physicians.

Schools of Nursing

Nursing represents the largest segment of the nation’s health care workforce. In 2000, an estimated 2.2 million registered nurses were employed full- or part-time nationwide (Health Resources and Services Administration, 2001). In terms of level of training, most (57 percent) registered nurses have received less than a baccalaureate degree4 as their highest nursing-related educational preparation, and 9 percent (196,300) have had formal preparation to practice in advanced nursing positions (e.g., nurse practitioner or nurse anesthetist) (Health Resources and Services Administration, 2001).

Despite their apparent potential role in cancer prevention and early detection, there is scant information about what role nurses are playing in this area. A 1992 comprehensive review of the literature on nurses’ involvement in cancer prevention (with most of the papers in the literature published in the late 1980s) provides examples of nurse-led initiatives in patient and community education, prevention-related intervention, and research (Frank-Stromborg and Rohan, 1992). Other literature describes the roles of nurse practitioners in risk assessment, teaching, patient advocacy, and cancer screening programs aimed at early detection (Leslie, 1995). With few national surveys of nurses’ practice activities, however, it is difficult to judge the level of nurses’ involvement in cancer prevention. Some state assessments suggest that nurses rarely perform cancer prevention services. Nurses responding to a 1992 statewide survey in Florida, for example, reported performing screening examinations or counseling about lifestyle changes with less than 20 percent of their patients (Entrekin and McMillan, 1993).5

Current information on the settings in which nurses practice suggests that the role of nursing in primary care may be limited, insofar as relatively few nurses work in ambulatory and community-based settings, the places most associated with cancer prevention activities. In 2000, most

4  

Among the three primary types of education that allow a person to enter an entry-level position in nursing (diploma, associate degree, baccalaureate), the education required for a baccalaureate, with its broader, more scientific curriculum, provides a foundation from which a nurse may move into graduate education.

5  

Although an attempt was made to reach a representative sample of nurses in the state, the survey response rate was only 36 percent, limiting the ability to interpret the study’s findings.

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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registered nurses (59 percent) worked in hospitals, an estimated 18 percent (402,900) worked in public or community health settings (e.g., state and local health departments and community health centers), and 9 percent (209,200) worked in ambulatory care settings. In these settings, evidence suggests that nurses do not routinely interact with patients—in 1998, an estimated 20 percent of ambulatory care visits involved a nurse (a registered nurse or an advanced practice nurse) or a physician’s assistant spending time with patients. A study of African-American nurses conducted in 1990 suggested that nurses are performing cancer prevention activities on a voluntary basis rather than on the job (Olsen and Frank-Stromborg, 1994). The barriers to providing cancer prevention activities reported by nurses include time limitations and a lack of specialized knowledge (Genovese and Wholihan, 1995).

The National Council of State Boards of Nursing administers licensure examinations and periodically conducts a national practice analysis of newly licensed registered nurses to ensure a match between the contents of the licensure examinations and contemporary practices. The 1999 practice analysis found that the majority of newly licensed registered nurses were employed in hospitals (87 percent) and that less than 5 percent were employed in community-based settings. Results of the activity analysis suggest that in these settings newly licensed nurses are completing health risk assessments (83.0 percent), counseling clients regarding risk behaviors (77.9 percent), teaching clients about health risks and health promotion (73.0 percent), and performing age-specific screening examinations (41.7). They are less likely to be involved in community-based activities such as participating in health promotion programs (35.5 percent) or helping to determine health promotion needs (10.8 percent). An estimated 4 to 10 percent of the licensure examination is devoted to prevention and early detection of disease (section B4 of the examination) (http://www.ncsbn.org/files/diagnostic/pndefin.asp).

Nurses’ level of interest in continuing education in cancer prevention, when it has been assessed, has not been high. According to an oncology education needs survey of 3,714 registered nurses in Texas, to which 378 nurses responded, training in prevention and screening was rated lowest in terms of priority relative to treatment-related topics (e.g., issues and trends in cancer care and investigational or new drug developments), even though perceived skill levels in prevention and screening were relatively low. This is likely explained by the fact that most of the nurses responding to the survey worked in hospital settings (Becker et al., 1995). Nursing workforce projections suggest that the hospital will remain the major employer of registered nurses but that in the future, because of a shift of care to outpatient settings and the aging of the population, nurses will need to focus on primary care and health promotion (http://bhpr.hrsa.gov/dn/bwrepex.htm).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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Nurse Training

Approximately 95,000 nurses graduate each year from about 1,500 programs for registered nurses at schools of nursing, and approximately 3,500 nurse practitioners graduate annually from more than 150 certificate- or master’s-level educational programs nationwide (National League for Nursing, 1997; Reed and Selleck, 1996). Master’s degree programs in advanced practice oncology nursing are also available (Brown and Hinds, 1998), and as of 1997 the Oncology Nursing Society had certified an estimated 19,000 nurses as oncology nurses and 1,300 as advanced oncology nurses (J. Mills, ONS, personal communication, March 28, 2002). Although most oncology nurses work in clinical settings, some are involved in community-based education programs focused on prevention. The Oncology Nursing Society’s Statement on the Scope and Standards of Oncology Nursing Practice (Oncology Nursing Society, 1996) and its Standards of Oncology Nursing Education (Oncology Nursing Society, 1995) include an emphasis on prevention, early detection, and health promotion.

At the time of writing of this chapter, there were no comprehensive reviews of nursing curricula, texts, or continuing educational opportunities in the area of cancer prevention and early detection. A few descriptions of attempts at integrating cancer prevention into nursing curricula (Mundt, 1996) and attempts to address the needs of certain groups of nurses are available. In recognition of the potential role of African-American nurses in promoting cancer prevention, for example, a cancer prevention and early detection program for nurses working with African Americans was developed. The curriculum includes learning objectives, detailed content outlines, lists of resources for professional and public education, and instruments for program evaluation (Underwood, 1999). One survey of African-American nurses who had enrolled in an NCI or Oncology Nursing Society workshop suggested that the majority of nurses were not participating in cancer prevention or screening activities before workshop participation (Olsen and Frank-Stromborg, 1994). In one assessment, nurse practitioners rated their clinical skills as excellent but rated their skills in patient education and counseling about cancer risk lower (Tessaro et al., 1996).

Training in Smoking Cessation in Nursing Education

Most oncology nurses who participated in a 1998 survey (38 percent response rate) could not recall whether they had received information about smoking or tobacco use prevention or cessation in their nursing curricula. Of those who did recall their student experience, most reported an absence of curricular content on prevention or the cessation of smoking or tobacco use. The majority of respondents said that they assessed and documented

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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the smoking or tobacco use status of their patients and had assessed their patients’ readiness to quit, but few went on to provide interventions. Common barriers reported by oncology nurses included a perceived lack of patient motivation and the nurse’s lack of time and skills (Sarna et al., 2000). Most stated that they needed additional training. A survey of nursing programs in Minnesota indicated that cancer prevention and early detection components were addressed at various levels of depth (Post-White et al., 1993). A resource for nurses is a World Wide Web-based smoking and tobacco use cessation information program created by the American Nurses Foundation (http://www.con.ohio-state.edu/tobacco/).

Dental Schools

Dental providers are second only to physicians in having high rates of access to the population: in 1998, nearly two-thirds (63 percent) of adults reported that they had seen a dental provider in the previous year. Many oral conditions, including oral cancer and periodontitis, are attributed to smoking and tobacco use, and so the prevention of smoking and the use of smokeless tobacco, as well as the treatment of nicotine addiction, are major concerns in dental practice. Dental patients, perhaps more so than medical patients, represent a “captive audience” for which there are “teachable moments” (Jones, 2000). Regularly scheduled dental hygiene visits also provide oral health care professionals with a unique opportunity to reiterate smoking-related messages and provide support for patients attempting to quit (Severson et al., 1998).

Like physicians, dentists are not routinely advising their patients who smoke to quit (http://www.ada.org/public/media/newsrel/9905/nr-03.html; Chisick, 2000; Hastreiter et al., 1994; Martin et al., 1996; Tomar et al., 1996). According to a 1994 national survey of oral health care providers, for example, only one-third of dentists and one-quarter of dental hygienists said that they asked most or nearly all of their patients if they smoked. Among the dentists surveyed, 66 percent reported that they advised most or nearly all of their patients who reported smoking to stop. Only 20 percent of dentists surveyed believed that they were well prepared to assist patients in stopping smoking and tobacco use, and only 14 percent of dentists had completed formal training in the provision of tobacco use cessation services. The training experiences cited included continuing education courses, pharmaceutical company-sponsored educational programs, the dental school curriculum, and organized study clubs. Those who reported having had some training in smoking and tobacco use cessation were more likely to report providing services in their practices (Dolan et al., 1997).

In 1991 and 1992 the American Association of Dental Schools published curriculum guidelines recommending that dental and dental hygiene students be educated about the effects of tobacco on oral health and that

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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students be able to conduct primary prevention counseling, assist with elimination of harmful habits, and assess compliance (Barker and Williams, 1999). More recently, a national strategic planning conference working group on professional education and practice recommended the development of health care curricula requiring competency in prevention, diagnosis, and multidisciplinary management of oral cancers, including the prevention and cessation of tobacco and alcohol use (CDC, 1998b). A 1998 review of the curricula in 47 of the nation’s 52 dental schools revealed that only 33 percent of the schools taught smoking cessation as part of the curriculum. Continuing education in cancer for community dentists was provided by 60 percent of the schools. Lack of funding was cited by 57 percent of the schools as the primary reason why continuing education was not being offered. In 1998, very few (15 percent) dental schools reported that they had received financial support from NCI, representing a significant decline relative to that in 1981, when half (51 percent) of dental schools received such support (Rankin et al., 1999). Another survey assessed smoking and tobacco use cessation activities in U.S. dental and dental hygiene student clinics and found that 47 percent of dental schools incorporated clinical practices in smoking and tobacco use cessation in their student clinics (Barker and Williams, 1999). A study of fourth-year dental students at one school that did not have formal didactic or clinical programs specifically devoted to training in smoking and tobacco use cessation suggested that the lack of training lowers the rate of tobacco use counseling (Yip et al., 2000).

Training in Smoking and Tobacco Use Treatment Among Providers Outside of Medical, Nursing, and Dental Schools

Voluntary organizations have a long history of training volunteers (both health care professionals and laypeople) to provide smoking and tobacco use cessation education and counseling services, often in group settings. The American Lung Association (ALA) has, for example, offered its Freedom from Smoking Cessation Clinics for more than 20 years, and it has recently launched a new program targeted to teens (C. Pruitt, ALA, personal communication. February 22, 2001). The clinics are staffed by individuals who undergo a day-and-a-half educational program. Another, more advanced program is available to train trainers. ALA recently placed its cessation program online (www.lungusa.org).

A few states have organized training programs that certify smoking and tobacco use treatment providers (Box 8.4). Massachusetts has developed a rigorous program aimed at training providers skilled in treating more complex cases. Arizona provides certification at two levels: a basic skills course for those interested in providing brief interventions and a specialist course for those providing more intensive services. Mississippi is among the states

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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BOX 8.4 Examples of State Efforts to Train Smoking and Tobacco Use Treatment Providers

Massachusetts

Since 1993, the Massachusetts Tobacco Control Program (MTCP) has funded smoking and tobacco use treatment providers through the Massachusetts Department of Public Health to provide treatment services throughout the state. In 1997, MTCP contracted with the University of Massachusetts Medical School to develop a comprehensive statewide training and certification program for smoking and tobacco use cessation (Pbert et al., 2000) and a training program for tobacco treatment specialists was finalized in 1999. The training entails a basic 2-day training course, an intensive 6-day core certification training course, and a set of required continuing education courses after certification. To be eligible for certification, those completing the course work must document 2,000 hours of experience in smoking and tobacco use treatment; pass a written examination; and demonstrate integration of knowledge, skills, and experience by passing an oral defense of a case study presented to a review committee (Pbert et al., 2000; Ewy B., University of Massachusetts Medical School, personal communication, February 27, 2001).

Arizona

The Arizona Cessation Training and Evaluation Program offers two curriculum tracks (www.tepp.org/actev/training/right.html):

  1. Smoking Use and Tobacco Cessation Skills Certification training is offered at three levels:

    • Basic skills—A 4-hour course open to anyone interested in helping individuals reduce tobacco dependency. Those certified in basic skills deliver brief interventions appropriate to a client’s readiness to quit and give clients advice about the use of nicotine replacement and help them create a simple quit plan. Since April 1999, more than 800 individuals have been certified in basic skills.

    • Specialist—A 16-hour course offered to health care and human services professionals experienced in smoking and tobacco use cessation. Those certified as a Tobacco Cessation Specialist are able to offer intensive smoking and tobacco use cessation services within the structure of an existing program, as well as to act as a resource for other professionals. More than 100 persons are certified as Tobacco Cessation Specialists in Arizona.

    • Trainer—The trainer curriculum, which is under development, will train individuals to develop or manage smoking and tobacco cessation programs and act as leaders in their communities and organizations.

  1. Systems training for individuals in health care, workplace, and school settings. The focus in this 16-hour course is on policy change, analysis of case studies, and review of best practice standards.

The Arizona Tobacco Education and Prevention Program posts tobacco cessation service providers’ compliance with guidelines of the Agency for Healthcare Research and Quality on the World Wide Web.

Mississippi

Since 1998, Mississippi has used its tobacco settlement money to provide training to more than 1,000 physicians and allied health care providers throughout the state. Smoking cessation products have recently been approved for reimbursement under the Medicaid program, but reimbursement for Medicaid providers awaits implementation of a certification process for smoking cessation providers (T. Payne, University of Mississippi Medical Center, personal communication, February 21, 2001).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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that are in the process of planning a certification for smoking and tobacco use treatment providers.

There have been calls for a nationwide certification program for smoking and tobacco use treatment specialists or at least a core curriculum that states could adapt for their needs. Concerns raised by requiring certification for smoking and tobacco use treatment providers include the cost of obtaining certification, the potential to exclude uncertified health care professionals from delivering basic smoking and tobacco use treatment, and integration of services in the health care delivery systems and the community (Pbert et al., 2000). Potential benefits of certification include quality assurance (e.g., providing services consistent with accepted guidelines), enhanced opportunities for reimbursement, and improved access to and recognition of smoking and tobacco use treatment.

Continuing Education

Health care providers who completed their training 10 or more years ago are unlikely to have been adequately trained in cancer prevention and early detection. In the early 1990s, for example, relatively few medical schools had any training in smoking cessation. Therefore, reaching providers after they have completed their training with continuing medical education (CME) programs is vital to improving the practice of cancer prevention and early detection.

Physicians seem to be interested in learning more about improving their office management of cancer prevention and screening activities. In a CME needs assessment survey conducted among primary care physicians in Massachusetts in 1990, this topic was the first preference of internists, family practitioners, and gynecologists. Almost all physicians (91 percent) indicated that they would find useful a comprehensive course on cancer prevention and early detection, with an emphasis on practical matters and with an opportunity to upgrade their clinical skills in physical examinations and counseling. Appealing to practitioners was a 1-day course that would lead to accreditation in screening and prevention and to reductions in malpractice premiums (Costanza et al., 1993).

A number of approaches have been used to provide continuing education to physicians, nurses, and dentists:

  • Online continuing education. Web-based continuing medical education courses are convenient, relatively inexpensive, and can reach providers that may live far from medical schools or sites of traditional programs. Some evidence suggests that online CME is of interest to physicians (Richardson and Norris, 1997), but Internet use among physicians is not yet universal (Chin, 2001). There are examples of excellent free CME offerings in cancer prevention and early detection (e.g., An Evidence-Based Ap-

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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proach to Screening Breast, Prostate, & Colon Cancer [www.uwcme.org]), but they are difficult to locate, as there are few organized listings of online CME course offerings available to health care providers.

  • Point-of-care education. Patient-specific cancer prevention reminders that physicians see immediately before or as they see their patients provide immediate guidance to physicians and, when coupled with educational interventions, have resulted in the increased use of some prevention services (McPhee et al., 1991).

  • Academic detailing. Modeled after drug detailing developed by the pharmaceutical industry, academic detailing is an effort to provide continuing education in office practices. Such methods have been used to improve cancer prevention and early detection practices and have met with some success (Sheinfeld Gorin et al., 2000; Williams et al., 1994). In one example, educational visits to 221 inner-city physicians in Philadelphia led to substantial increases in cancer screening and prevention activities, as well as an increased confidence in counseling skills, as expressed by the physicians (Daly et al., 1993).

  • Supervised skill training. Acquiring the necessary skills to incorporate unfamiliar or new technologies into practice usually requires some hands-on supervised experience as well as didactic education. As part of a community-based demonstration and education project, primary care physicians in one community were offered skills training in flexible sigmoidoscopy. Their patients were those age 50 and older who had never had a sigmoidoscopy and who responded to an invitation to have the procedure at a reduced fee (Renneker and Saner, 1995).

  • Train the trainer. In 1989 NCI developed a 3-hour course for physicians and nurses and collaborated with organizations to reach providers in a train-the-trainer model of delivery (Manley et al., 1991). The goal of the program was to train 100,000 physicians.

  • Multimethods. Multimethod CME approaches have been used to reach larger numbers of physicians through preferred (and perhaps different) learning styles. One such effort to improve compliance with mammography guidelines was based at a community hospital and was directed at physicians with hospital staff appointments engaged in fee-for-service office practice in the community. Educational interventions included formal CME conferences, a physician newsletter, breast examination skills training, a breast cancer CME monograph, primary care office visits, patient education materials, and a “question of the month” at hospital staff meetings. The package of interventions available to physicians increased referrals of asymptomatic women ages 50 to 75 (Lane et al., 1991).

  • Development of educational materials. Put Prevention into Practice, a program sponsored by the Office of Disease Prevention and Health Promotion of the U.S. Public Health Service, was a multifaceted educational initiative consisting of a variety of printed materials made available in 1994

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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to providers, to patients, and in the office setting (Gemson et al., 1996). Consistent with other studies, the simple availability of a kit of materials is not sufficient to enhance the delivery of prevention services. Additional strategies for dissemination and implementation are needed, such as providing external consultation services to practices and adopting reminder systems (Goodson et al., 1999; Kikano et al., 1997; Medder et al., 1997; Weingarten, 1999).

A recent review of the effectiveness of approaches to CME suggests that interactive CME sessions that enhance participant activity and that provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes (Davis et al., 1999). Performance-based learning, such as role playing and use of simulated or standardized patients, are especially effective in improving performance (Carney et al., 1995; Davis et al., 1999; Ockene and Zapka, 1997). Academic detailing, in which educators provide face-to-face education in an interactive manner within the practice setting, has been found to be effective (Daly et al., 1993; Davis et al., 1995a) and addresses the issue of limited provider time. Traditional continuing medical education strategies of lectures, grand rounds, or brief noon or morning reports can improve physicians’ knowledge and awareness, but when used alone, they generally do not change a physician’s clinical practice (Davis et al., 1999; Haynes et al., 1984; U.S. Preventive Services Task Force, 1996).

CME in cancer has been critiqued as being “off target” too often with too little emphasis on smoking cessation, for which there is ample evidence that providers are not trained. It has also been critiqued for not giving physicians opportunities to learn about office management or organizational interventions that could improve compliance with cancer prevention and early detection recommendations (Love, 1993). Some evidence suggests that provider training alone is not enough. Training of physicians in smoking cessation interventions appears to be most effective when it is paired with changes in the use of other systems, such as staff education and clinic reminder systems (US DHHS, 2000a). Several randomized clinical trials demonstrate, for example, the efficacy of physician training in combination with the implementation of office system innovations for smoking cessation (e.g., placement of stickers in the charts of smokers) (Cohen et al., 1987, 1989; Cummings et al., 1989a,b; Gilbert et al., 1992; Janz et al., 1987; Kottke et al., 1989; Lindsay et al., 1994; Ockene et al., 1991b; Manley et al., 1991; Wilson et al., 1988; Chang et al., 1995).

Similar findings have emerged from studies of educational interventions to improve physicians’ provision of dietary counseling (Dietrich et al., 1992; Ockene et al., 1996; Tziraki et al., 2000) and physical activity counseling (Marcus et al., 1997; Pinto et al., 1998). Other research suggests that the development and implementation of office systems by themselves can

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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substantially improve provision of cancer detection and early prevention services (Dietrich et al., 1992; McPhee et al., 1991). In fact, some have suggested that the major vehicle for improved clinical prevention services is the establishment of office systems that are conducive to meeting prevention needs during the course of normal patient care (Solberg et al., 1997a).

SUPPORT FOR PROFESSIONAL EDUCATION AND TRAINING

Public Programs

National Cancer Institute

A number of education and training opportunities are supported through NCI’s Office of Centers, Training, and Resources. The Cancer Training Branch of this office plans, develops, administers, and evaluates the extramural, grant-supported research training and health professional education programs of NCI in the form of fellowships and institutional grants. Additional education and training opportunities at NCI exist through other programs such as the Cancer Centers Program and the Cancer Prevention Fellowship Program. Through the Office of Centers, Training, and Resources, NCI provided roughly $30 million in fiscal years 2000 and 2001 to support education and training in cancer prevention and early detection (Brian Kimes, director, Office of Centers, Training, and Resources, personal communication to Maria Hewitt, Institute of Medicine, November 14, 2001). Support is available both to training institutions and to individuals pursuing graduate and postgraduate training (Table 8.1).

The R25 grant has been used as a training instrument by NCI for years, but it has a varied history. NCI began awarding R25 grants to medical schools in 1948 on a noncompetitive basis to provide more education on cancer and to encourage faculty to pursue oncology. Between 1966 and 1983, medical schools competed for grants. In the 1980s, the R25 training grant program was cut because of NCI budget reductions, and an estimated one-third of medical schools lost funds. For some schools not able to find alternative funding sources, the number of cancer education faculty declined (Chamberlain et al., 1992). When support was assessed in 1989–1990 in Cancer Education Survey II, 66 of 125 medical schools had been the recipients of an NCI R25 training grant. NCI R25 training grant support was viewed as instrumental in maintaining key elements of the cancer education program, such as cancer education coordinators, cancer education committees, and student assistantships and fellowships (Chamberlain et al., 1992; Gallagher et al., 1992). In 1999, the NCI R25 grant was revamped as a training instrument with a new focus on preparing scientists who can work in multidisciplinary, team research settings. This newest version of the R25 grant is called the R25T grant and can support both

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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TABLE 8.1 National Cancer Institute Research Training and Career Development Opportunities for Prevention, Control, Behavioral, and Population Scientists

Program

Description

Support Level

Cancer Education and Career Development Program (R25T grants)

Institutional award for education and training predoctoral and postdoctoral candidates in multidisciplinary research settings

Up to 5 years of support, not to exceed $500,000 in direct costs per year (can exceed this level with special permission); grants are renewable

Cancer Prevention, Control, Behavioral and Population Sciences Career Development Award (K07 grant)

Institutional award for postdoctoral training

Annual salaries up to $75,000 plus fringe benefits and other costs up to $30,000; up to 5 years of support available; grants are not renewable

Transition Career Development Award (K22 grant)

Award to clinician-scientists or prevention control,behavioral,and population scientists to provide “protected time ” to develop independent cancer research

Annual salaries up to $75,000 plus fringe benefits and other costs up to $50,000; up to 3 years of support available; grants are not renewable

Established Investigator Award in Cancer Prevention, Control, Behavioral, and Population Research (K05 grant)

Award to institutions for scientists with outstanding track records in research and who need protected time to devote to their research and to act as mentors for new investigators

Annual salaries up to 50 percent of the maximum allowable federal salary plus fringe benefits and other research costs up to $25,000; grants are renewable for one additional 5-year period

Cancer Education Grant Program (R25E grant)

Award to organizations for innovative education programs (e.g., academic short courses, national forums, and hands-on workshops)

Up to $300,000 in direct costs for any single year

 

SOURCE: http://cancertraining.nci.nih.gov/research/prevention/pr25t.html, accessed December 5, 2000.

predoctoral students and postdoctoral fellows for up to 5 years, with a cap of $500,000 in direct costs per year (http://cancertraining.nci.nih.gov/research/prevention/pr25t.html). The R25T grant is particularly adaptable to training cancer prevention and control and population scientists. One recent example of a program awarded an R25T grant is the Tobacco Research Training Program, in which individuals are trained in multidisciplinary research settings and have more than one mentor during the course of their training.

The other large organizational award that uses the R25 grant mecha-

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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nism is the traditional Cancer Education Grant Program, which provides R25E grants at funding levels of up to $300,000 per year. The following are among the projects that have been funded through this mechanism (http://cancertraining.nci.nih.gov/cancerEd/cancered.html):

  • a project that provides short introductory research opportunities for health professionals;

  • a project that designs, implements, and evaluates new curricula of special significance to cancer (e.g., nutrition);

  • a project that develops a curriculum for health care professionals in cancer pain management and palliative care;

  • programs that offer outreach to the lay community; and

  • workshops, national forums, short courses, and hands-on experiences (e.g., minority health initiatives, courses on state-of-the art basic research techniques).

One recent specific example of work funded by an NCI R25E grant is an effort to improve cancer prevention education across Texas. A consortium of eight Texas medical schools has charged 50 faculty “champions” with developing instructional resources, sharing their expertise, and leading the way in making changes to the curricula in their local institutions. Goals are to progress toward longitudinal integrated curricula, performance-based education, and competency-based testing (www.catchum.utmd.edu/catchumgoals.htm).

A number of other special programs at NCI provide support for individuals to pursue training in cancer prevention and early detection:

  • The Cancer Prevention Fellowship Program provides multidisciplinary training in cancer prevention and early detection.

  • The NCI Scholars Program provides for up to 4 years of research support in the laboratories or clinics of NCI for investigators who are ready to begin independent research careers.

  • The Division of Cancer Epidemiology and Genetics offers fellowships and summer internships.

Centers for Disease Control and Prevention

CDC’s federally mandated National Breast and Cervical Cancer Early Detection Program, in addition to providing screening services to women, supports public and professional education. Examples of state-initiated activities that are offered through this program include the following (CDC, 1998a):

  • A self-study kit in Kentucky helps primary care physicians increase

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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their use of and improve their practice of routine breast and cervical cancer screening. The program features a videotape that discusses communication strategies, physical examination recommendations and techniques, risk management, and office reminder systems. Physicians who complete the study are awarded incentives including a 5 percent malpractice insurance premium reduction (CDC, 2000c).

  • A 3-day interactive course offered through the West Virginia Breast and Cervical Cancer Screening Program certifies public health nurses (primarily in county health departments and primary care centers) to perform breast self-examination education, clinical breast examinations, and pelvic examinations and Pap smears (S. Pickering, CDC, personal communication, March 20, 2001).

  • The development and distribution of a video-based self-study packet, Follow-up of Abnormal CBE [clinical breast examination] and Mammographic Findings, designed by the CDC National Breast and Cervical Cancer Early Detection Program ensures that primary care providers are aware of current protocols and practice standards for the follow-up of abnormal clinical breast examination and mammographic findings. The packet includes a two-part video and self-study manual, and CME credits are offered through CDC (S. Pickering, senior program consultant, CDC, personal communication, March 20, 2001).

  • A 2-hour satellite training conference for Alabama nurses and nurse practitioners provides training on follow-up of abnormal breast examinations. Continuing education credit is offered for this course (S. Pickering, CDC, personal communication, March 20, 2001).

  • An educational outreach to mammography facility staff assists with compliance with the Mammography Quality Standards Act (Public Law 102-539) in rural North Carolina (Pisano et al., 1998a).

  • Native Web was developed to enhance American Indian nurses’ clinical breast examination skills.

  • The Ohio Department of Health and the Ohio Breast & Cervical Cancer Project, in collaboration with the Medical College of Ohio, developed a CD-ROM, Cultural Competence in Breast Cancer Care, to enhance the capacity of primary health care providers (physicians and others) to effectively screen, evaluate, and manage breast cancer in culturally and ethnically diverse patient populations. The CD-ROM meets accreditationcontract and regulatory requirements for CME (S. Pickering, CDC, personal communication, March 20, 2001).

As part of an effort to generate a greater awareness among primary care providers of the importance of prevention and early detection of colorectal cancer, CDC staff have made available online a slide presentation, A Call to Action: Prevention and Early Detection of Colorectal Cancer (www.cdc.gov/cancer/colorctl/calltoaction/index.htm).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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Speakers from CDC are available to deliver the training slides at national or regional professional conferences.

In fiscal year 2001 CDC funded two initiatives to provide education on prostate cancer screening for primary health care providers, including potential benefits and harms, fundamentals of effective patient counseling, and informed decision making (http://www.cdc.gov/od/pgo/funding/01094.htm).

Health Resources and Services Administration

HRSA is one of eight agencies of the U.S. Public Health Service. Its programs cover Community and Migrant Health Centers, national maternal and child health needs, placement of physicians in medically underserved areas through the National Health Service Corps, and community-based human immunodeficiency virus infection and AIDS services. Through its Bureau of Health Professions, HRSA attempts to promote and maintain the nation’s supply of health professionals by supporting faculty to meet current health care challenges, designing new curricula, and providing student loans and scholarships to encourage lower-income, disadvantaged, and minority individuals to become health care professionals (Sampson, 1995). HRSA also funds primary care offices in each state health department and funds primary care associations to build statewide coalitions for primary care health delivery systems (Health Resources and Services Administration, 2000b).

As part of its charge, HRSA supports preventive medicine residency training. In 1998, HRSA provided $1.6 million to 11 schools to further advanced training (www.bhpr.hrsa.gov/dadphp/prevmed.htm). HRSA also supports public health traineeships to alleviate shortages of public health professionals in medically underserved areas or populations (www.bhpr.hrsa.gov/dadphp/phtrain.htm). In 1999, HRSA awarded 34 grants totaling $2.2 million to schools, and in 2000, HRSA awarded 33 noncompeting continuation grants totaling $1.8 million to schools. Innovations in curriculum in areas such as population health and providing primary care services to vulnerable, underserved populations will be supported by HRSA as part of a 5-year demonstration project, Undergraduate Medical Education for the 21st Century (www.aacom.org/UME/AboutUME).

HRSA oversees Area Health Education Centers (AHECs), which are programs housed within accredited schools of medicine and nursing that have the following objectives:

  • to form linkages between health care delivery systems and educational resources in underserved communities;

  • to create collaborative community-based education and training opportunities for health care professionals, students, and primary care resident physicians;

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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  • to create systems for learning and networks for information dissemination;

  • to support multidisciplinary and interdisciplinary training in response to community needs; and

  • to provide technical assistance to educators and others.

In 2000, HRSA provided about $40 million to 39 AHECs and 40 AHEC programs (www.bhpr.hrsa.gov). Some examples of cancer prevention-related education and training offered through AHECs follow:

  • A 2-day training session on cancer prevention and screening for nurses practicing in rural areas was designed in Colorado and delivered through AHECs. According to evaluation measures, it was successful in improving nurses’ knowledge, attitudes, and skills (Howell et al., 1998).

  • Continuing education on early detection of breast cancer was provided to 22 rural hospitals and clinics in Arkansas through interactive television linkages. The mammography seminar was attended by 136 mammographers, 40 clinics were provided breast examination training, and 40 nurse practitioners received training (CDC, 2000d).

HRSA also provides direct support for individual education and training:

  • HRSA and the Centers for Medicare and Medicaid Services support a health policy fellowship program for preventive medicine physicians through a cooperative agreement with the Association of Teachers of Preventive Medicine (www.atpm.org/news/press4.htm).

  • HRSA, in collaboration with CDC and the Association of State and Territorial Directors of Nursing, has developed a distance learning tool to teach core public health competencies. Called Waldtrek, the project has had three broadcasts and has enrolled an estimated 3,000 nurses (Carole Gassert, Division of Nursing, Bureau of Health Personnel, Health Resources and Services Administration personal communication to Maria Hewitt, January 2001). The broadcasts have covered principles of population health but nothing specifically related to cancer prevention.

HRSA’s Cancer Action Plan has proposed means of improving cancer prevention and early detection services (Health Resources and Services Administration, 2000a). The initiatives include:

  • the creation and dissemination of systematic training modules for primary care clinicians to increase their knowledge of cancer screening procedures (e.g., colonoscopy, colposcopy, endometrial biopsy, and fine-needle biopsy) and

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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  • strengthening the cancer prevention, screening, and access-to-care content of Division of Nursing training grants to nurse practitioner and nurse midwifery training programs.

Agency for Healthcare Research and Quality

Although the training opportunities provided by the Agency for Healthcare Research and Quality (AHRQ) are not specific to cancer, AHRQ provides several training opportunities in health services research of potential interest to clinical and behavioral and social scientists (www.ahcpr.gov/fund/training/trainix.htm):

  • Health Services Research Dissertation Awards (R03 grants)

  • Independent Scientist Awards (K02 grants) (career development support for promising new investigators)

  • Individual Postdoctoral Fellowship Awards (F32 grants)

  • Institutional Training Awards (T32 grants) (National Research Service Award grants to institutions for predoctoral and postdoctoral training)

  • Institutional Training Innovation Incentive Awards (R25 grants) (support for design and implementation of new models of health services research training)

  • Kerr White Visiting Scholars Program (intramural opportunities for junior, mid-career-level, and senior researchers)

  • Mentored Clinical Scientist Development Awards (K08 grants)

  • Opportunities for Minority Students

  • Predoctoral Fellowship Awards for Minority Students (F31 grants)

  • Summer Intern Program.

AHRQ also supports health services research, including methods to improve physicians’ preventive health practices.

Private Programs

American Cancer Society

The American Cancer Society (ACS) has spent an estimated $2 million to $3 million annually in recent years on training and career development in cancer prevention, representing roughly 20 percent of ACS’s total spending for training and career development (Ginger Krawiec, ACS, personal communication to Maria Hewitt, Institute of Medicine, April 11, 2001). Opportunities for support available through ACS are described in Table 8.2.

Some ACS-funded programs have been described in the literature. With funding from an ACS professional education grant, for example, nurses at

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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TABLE 8.2 Training and Career Development Opportunities, American Cancer Society

Program

Description

Support Level

Postdoctoral fellowships

Awards to individuals for research training (basic, preclinical, clinical, psychosocial, behavioral, and epidemiological research)

One-to 3-year awards with stipends of up to $40,000 per year plus a $2,000 per year institutional allowancea

Clinical research training grants for junior faculty

Awards to individuals to conduct mentored clinical, epidemiological, psychosocial, behavioral, or health policy and outcomes research

Up to 3 years for up to $150,000 per year,including 25 percent indirect costs; renewable once for a 2-year period

Cancer control career development awards for primary care physicians

Awards to academic physicians pursuing a career in cancer control research, teaching,and practice

Three-year award for up to $60,000 per year

Physician training awards in preventive medicine

Awards to institutions to support physician training in accredited preventive medicine residency programs

Four-year awards in the total amount of $300,000 based on an average of $50,000 per year for resident training

Master ’s and post-master ’s training grants in clinical oncology social work

Awards to institutions (master ’s level)and individuals (postdoctoral level)

One-to 3-year awards with annual funding from $12,000 (master ’s)to $20,000 (doctorate)

Master ’s and doctoral degree scholarships in cancer nursing

Awards to individuals

Up to two year (master ’s)and four year (doctorate)awards with a stipend of $10,000 (master ’s)or $15,000 (doctorate)per year

aTop-ranked fellows receive 3-year fellowships with an award amount of $138,000.

SOURCE: wysiwyg://40http://www2.cancer.org/research/index.cfm?sc=1, accessed December 5, 2000.

the Bronx Veterans Affairs Medical Center formed the VANAC (VA Nurses Against Cancer) team. After an intensive orientation, nurses participated in a wide range of educational activities, including patient education, staff seminars, and community presentations (Genovese and Wholihan, 1995). A hospitalwide Breast Health Awareness Team was organized as an off-shoot of the VANAC team, and some funded activities were maintained after the cessation of grant support (e.g., school of nursing presentations were continued).

American Association of Health Plans

In 1997, the American Association of Health Plans (AAHP), the professional organization representing managed care plans, with support from

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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the Robert Wood Johnson Foundation, CDC, and AHRQ, established the National Technical Assistance Office (NTAO) to help managed care organizations integrate smoking and tobacco use cessation activities into routine health care. NTAO’s mission is to (www.aahp.org/atmc/ntaosum.htm):

  • develop a comprehensive network of key contacts in health plans who are responsible for smoking cessation and health promotion;

  • establish a clearinghouse of smoking and tobacco use prevention information gathered from academic and professional journals, conferences, newsletters, and white papers;

  • provide technical assistance to health plans in developing smoking and tobacco use prevention and cessation programming, including the development and dissemination of a newsletter, a regularly updated annotated bibliography, an NTAO website, and phone and online consultations;

  • conduct a benchmarking awards program highlighting exemplary initiatives by health plans in smoking and tobacco use prevention and cessation;

  • distribute an annual survey to health plans to determine the current status of smoking and tobacco use cessation initiatives and to evaluate best practices; and

  • promote best practices in smoking and tobacco use cessation and prevention through a series of training workshops, national and regional conferences, and a managed care smoking and tobacco use prevention and cessation tool kit.

According to a survey of health plans conducted in 2000, 24 percent had employed a full- or part-time staff person specifically for smoking and tobacco use control activities, and 22 percent were implementing provider training programs for smoking and tobacco use cessation counseling (Anne Cahill, program manager, Prevention Programs, AAHP, personal commu nication, March 6, 2001).

American Legacy Foundation

The American Legacy Foundation, set up to administer funds from the Tobacco Master Settlement Agreement, has included as part of its strategic plan increases in the number of health professional schools that include training and education in smoking and tobacco use cessation in their curricula (www.americanlegacy.org/overview/strategic.html).

SUMMARY AND CONCLUSIONS

Despite numerous calls to improve the education and training of health

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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care professionals in health promotion and disease prevention, there is evidence of programmatic deficits in medical, dental, and nursing schools. A problem of greater magnitude is upgrading the knowledge and skills of practicing clinicians whose performance reflects their lack of training. The demand for behavioral and early detection services will increase as the population ages, placing new strains on ambulatory care providers. Some solutions follow:

  • requirements that educational institutions meet established curriculum guidelines (e.g., the population health guidelines of AAMC),

  • inclusion of cancer prevention and early detection questions on national board and licensure examinations,

  • assurances that adequate continuing education opportunities are available through training institutions and professional organizations,

  • applications of new learning technologies (e.g., distance learning and online CME),

  • assessments of the adequacy of the future supply of providers, and

  • research and demonstrations to test different delivery models to clarify who should be trained and how interventions can be best be delivered.

Although education alone is not sufficient to change the behaviors of providers, it remains an important factor in ensuring the delivery of evidence-based standard practices for cancer prevention and control. Many reciprocal factors can affect provider and patient behaviors at the health care plan and organizational levels. Structure and process characteristics, such as the availability of automated clinical reminder systems and quality improvement expectations, can enable and reinforce the practice of providing the needed prevention services. Required educational programs coupled with a system that identifies at-risk patients and that reminds the provider to intervene will produce increases in providers’ rates of provision of counseling (Adams et al., 1998; Fiore et al., 1996, US DHHS, 2000a; Ockene et al., 1996).

Suggested Citation:"8. Professional Education and Training." Institute of Medicine and National Research Council. 2003. Fulfilling the Potential of Cancer Prevention and Early Detection. Washington, DC: The National Academies Press. doi: 10.17226/10263.
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Next: 9. Federal Programs That Support Cancer Prevention and Early Detection »
Fulfilling the Potential of Cancer Prevention and Early Detection Get This Book
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Cancer ranks second only to heart disease as a leading cause of death in the United States, making it a tremendous burden in years of life lost, patient suffering, and economic costs. Fulfilling the Potential for Cancer Prevention and Early Detection reviews the proof that we can dramatically reduce cancer rates. The National Cancer Policy Board, part of the Institute of Medicine, outlines a national strategy to realize the promise of cancer prevention and early detection, including specific and wide-ranging recommendations. Offering a wealth of information and directly addressing major controversies, the book includes:

• A detailed look at how significantly cancer could be reduced through lifestyle changes, evaluating approaches used to alter eating, smoking, and exercise habits.

• An analysis of the intuitive notion that screening for cancer leads to improved health outcomes, including a discussion of screening methods, potential risks, and current recommendations.

• An examination of cancer prevention and control opportunities in primary health care delivery settings, including a review of interventions aimed at improving provider performance.

• Reviews of professional education and training programs, research trends and opportunities, and federal programs that support cancer prevention and early detection.

This in-depth volume will be of interest to policy analysts, cancer and public health specialists, health care administrators and providers, researchers, insurers, medical journalists, and patient advocates.

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