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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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).
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Fulfilling the Potential of Cancer Prevention and Early Detection 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).
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Fulfilling the Potential of Cancer Prevention and Early Detection 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).
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Fulfilling the Potential of Cancer Prevention and Early Detection 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.
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Fulfilling the Potential of Cancer Prevention and Early Detection 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;
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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): clinical prevention services, quantitative methods, community dimensions of medical practice, and 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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-
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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).
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Fulfilling the Potential of Cancer Prevention and Early Detection 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;
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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
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Fulfilling the Potential of Cancer Prevention and Early Detection 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).
Representative terms from entire chapter: