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Identifying opportunities for PharmD curricular reform by surveying oncology pharmacists about career preparedness and exposure
Currents in Pharmacy Teaching and Learning 11 (2019) 1205–1212
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Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Research Paper
Identifying opportunities for PharmD curricular reform by surveying oncology pharmacists about career preparedness and exposure
T
Sara A. Thompsona, Margie E. Padillab, , Amanda M. Loyab, Mary L. Chavezb, Jessica Shenberger-Trujillob ⁎
a b
North Dakota State University School of Pharmacy, NDSU Dept. 2650 / PO Box 6050 / Fargo, ND 58108-6050, United States The University of Texas at El Paso School of Pharmacy, 500 W. University, El Paso, TX 79968, United States
ARTICLE INFO
ABSTRACT
Keywords: Oncology Curriculum Preparedness Mentorship
Introduction: The primary objective of the study was to assess factors that predict pursuit of an oncology post-graduate year 2 (PGY-2) residency. Additional objectives included identifying the role of and exploring opportunities for PharmD curricula to increase student interest in the oncology field. Methods: An anonymous 15-minute survey was developed and administered to oncology pharmacists and residents. Study participants were included if they were actively practicing as clinical pharmacists in an oncology setting in the US, maintained an active pharmacist license, and > 18 years of age. Responses were analyzed using descriptive and inferential statistics. All results are reported in aggregate, with the exception of quotes obtained from open-ended responses. Results: Eighty participants were included in analyses. After controlling for variance due to age, sex, race, years of practice, the number of oncology advanced pharmacy practice experiences (APPEs) correlated with pursuit of a PGY-2 residency in oncology (p = 0.047). Additionally, participants' perceived level of preparedness from didactic oncology training predicted pursuit of an oncology PGY-2 residency (p = 0.002). Emerging themes in pursuing oncology from openended items revealed that inclusion of supportive care in the didactic curriculum and having a family member or friend diagnosed with cancer were important factors. Additionally, participants' responses regarding PharmD curricula included recommendations to inform didactic and experiential education. Conclusions: The results support the need for reevaluation of oncology education in PharmD curricula. Further studies could explore specific aspects of didactic curriculum that impact the level of student preparedness, and which elements encourage a student pharmacist to seek further training in the oncology field.
Introduction The field of oncology has experienced an increase in treatment options with 16 new drug approvals in 2017 alone, in addition to the first agent to receive approval based on a tumor's biomarker and not the origination site.1 This ever-growing armamentarium has Corresponding author. E-mail addresses: [email protected] (S.A. Thompson), [email protected] (M.E. Padilla), [email protected] (A.M. Loya), [email protected] (M.L. Chavez), [email protected] (J. Shenberger-Trujillo). ⁎
https://doi.org/10.1016/j.cptl.2019.09.002
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
Currents in Pharmacy Teaching and Learning 11 (2019) 1205–1212
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led to complex regimens and more involvement between interdisciplinary health care providers to provide optimal care. As a result, there is a growing need for oncology trained healthcare professionals. An American Society of Clinical Oncology (ASCO) report determined that over 12,000 oncologists and hematologists provided care to cancer patients in 2016.2 Approximately 20% of practicing oncologists are older than 64 years and nearing retirement, with some geographic regions reporting insufficient younger oncologists entering the field. Reasons for this impending shortage are multifaceted and include retirement, increased demand for practitioners as the population ages, and burnout. As the population ages, in combination with better survival outcomes for many malignancies, the number of cancer survivors will increase. It is projected the number of cancer survivors will reach 20 million in the United States (US) by 2026.3 Additionally, the Cancer Moonshot Initiative aims to focus on the prevention and treatment of malignancy via a multitude of initiatives and interdisciplinary relationships (e.g., pharmacists, physician assistants, nurses). Former Vice President Joe Biden reinforced these objectives at the 2016 ASCO meeting.4 A solution proposed by the ASCO Chief Medical Officer Richard L. Schilsky is the incorporation of advanced practice providers into offices and clinics that provide care to cancer patients.5 This newly expanded workforce could include highly-trained clinical pharmacists.6 Clinical pharmacists are called upon to contribute to the care of oncology patients. The concern of how to approach training in the PharmD curriculum with respect to oncology has been recently posited.7 Therapeutic factors, such as drug therapies in oncology that increase in both number and complexity, increasing cost of therapy, as well as the flourishing field of cancer survivorship, have implications to the pharmacist's contributory role and responsibility. Newton and colleagues contend it is no longer sufficient to consider the care of oncology patients solely the responsibility of specialty trained pharmacists.8 Rather, any pharmacist may be called upon to interact with oncology patients from initial diagnosis to end-of-life care as necessary. This potential role signifies a need to prepare future pharmacists to care for the oncology patient in a variety of practice settings. The growing need for pharmacists to care for the cancer patient in a multitude of settings necessitates an evaluation of PharmD curricula with respect to oncology training. One recent study surveyed chairs of clinical pharmacy practice departments in all US pharmacy programs in 2013.9 Of the schools/colleges that responded (47% of those surveyed), department chairs reported a wide range in the number of contact hours dedicated to oncology topics in the didactic curriculum (i.e. 1–85 hours). Experiential education opportunities in oncology were also available but demand for placements in oncology advanced pharmacy practice experiences (APPEs) was low. Though limited by response rate, the findings of this study elucidate potential opportunities in PharmD curricula, such as reevaluation of the oncology component of the curriculum and increased exposure to experiential oncology opportunities. Other studies have specifically explored pharmacy student interests in oncology as well as oncology training opportunities for pharmacists already in practice.10,11 Data from investigations into pharmacy student interests have revealed that despite an interest in the field, many students have a lack of comfort with and knowledge of oncology.10 Post-graduate formal training opportunities in oncology have shown to be promising by increasing the oncology knowledge of pharmacists; however, results are limited by high drop-out rates, small sample sizes, and the unlikely prospect of pharmacists prioritizing these training opportunities while completing job responsibilities.11 These studies suggest that formal instruction in the PharmD curriculum and residency training would the best approach to adequately prepare pharmacists to practice in this field. However, at this time it appears no study has specifically examined the preparedness, exposure, and training received by pharmacists prior to practicing as clinical pharmacists in the oncology setting. The primary objective of this study is to assess factors that impact the pursuit of a post-graduate year two (PGY-2) residency in oncology, with additional objectives of identifying and exploring strategies in PharmD curricula to increase student interest in the oncology field. This study aims to stimulate discussion among pharmacy programs regarding best practices in the development of a curriculum that may optimally prepare student pharmacists to serve oncology patients. Methods The current study was conducted by researchers at a university in the southwest region of the US. A survey was developed to assess various elements of practice preparedness, exposure and support related to oncology pharmacy (Table 1). The survey consisted of a demographic section, which included items regarding age, gender, highest degree earned, training completed, credentials, and practice area. This was followed by a more detailed inquiry of participants' personal experiences related to their trajectory as oncology pharmacists. This latter portion of the survey was called the Oncology Experience Survey (OES). The OES contained 24-items in total (dependent on certain answers to skip-logic questions in which topics that were not applicable to the individual such as residency experiences were skipped) and was estimated to require 15 min to complete. The OES focused on factors that support or discourage pursuit of a career in oncology pharmacy. A total of 13 questions were assessed for quantitative analysis of results (i.e. Likert scale response options raged from a value of 1 to 5), while 11 items were included for qualitative analysis (i.e. open ended items). Sample items include training that increased interest, instrumental support in preparation for a career in oncology, and mentorship. Open-ended questions also included recommendations for PharmD and resident learners. Prior to commencement of data collection, the survey was pretested by a small cohort of oncology pharmacists (n = 3) to provide feedback for improvement of the survey. Minor adjustments were made as a result of recommendations (e.g., grammar) from the pretest population. Study participants were included if they were actively practicing US clinical pharmacists in the oncology setting, had an active pharmacist license, and were at least 18 years of age. Thus, participants reflect a national sample of pharmacy practitioners. Individuals who do not practice in oncology, nor have an active pharmacist license, were post-graduate year 1 (PGY-1) residents at the time of the survey, or participants with incomplete responses (< 50%) were excluded. Current practicing oncology pharmacists were recruited via several means. Current post-graduate year 2 (PGY-2) oncology 1206
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Table 1 Sample items from the Oncology Experience Survey (OES).a To To To To To To
what what what what what what
extent extent extent extent extent extent
do do do do do do
you you you you you you
feel feel feel feel feel feel
your your your your your your
didactic oncology curriculum prepared you for your current position in oncology? didactic oncology curriculum increased your interest in pursuing oncology? experiential oncology curriculum prepared you for your current position in oncology? experiential oncology curriculum increased your interest in pursuing oncology? post-graduate training prepared you for your current position in oncology? post-graduate training increased your interest in pursuing oncology?
Open-ended items If there were specific components of the didactic curriculum that prepared you, please describe If there were specific components of the experiential curriculum that prepared you, please describe If there were specific components of your post-graduate training that prepared you, please describe What recommendations do you have for oncology training in PharmD programs? Please consider recommendations for the a) didactic curriculum, b) experiential curriculum, and c) for co-curriculum or interprofessional education. What recommendations do you have for resident learners? Other items What experience in oncology did you have in advanced pharmacy practice experiences (APPEs)? Did you pursue a post-graduate year 2 (PGY-2) residency in oncology? Was there an impactful personal experience or event that was instrumental in your decision to pursue oncology? Did you experience significant support in your pursuit of a career in oncology? Did you experience setbacks, challenges, or obstacles in your pursuit of a career in oncology? Did you have a mentor who encouraged you in oncology? Do you currently mentor students interested in oncology? a
Likert type item response options varied from a value of 1 to 5.
pharmacy residency program directors (RPDs) were identified via contact information from the American Society of Health-System Pharmacists (ASHP) residency directory. Additionally, an announcement was sent to the Hematology/Oncology network group of the American College of Clinical Pharmacy (ACCP). Participants were also encouraged to share the survey with interested oncology pharmacy colleagues and residents. Table 2 Demographics. n (%) Age in years (n = 78) (SD) Gender - N (%) Male Female Race - N (%) American Indian/Alaskan Native Asian/Asian American African American/Black Native Hawaiian/Pacific Islander White/Caucasian Other Hispanic/Latino - N (%) Yes No No answer Board certification N (%) BCOP (alone or in combination) BCPS (alone or in combination) BCACP (in combination) None Post-graduate training (%) PGY1 residency PGY-2 residency PGY1 and 2 residencies Years in practice (SD) Practice setting (%) Outpatient Outpatient and other settings Inpatient Inpatient and other settings Infusion center (alone or in combination) Academia (in combination)
PGY1 = post-graduate year 1; PGY2 = post-graduate year 2. 1207
39 (10) 28 (35) 52 (65) 1 (1.3) 10 (12.5) 0 (0) 1 (1.3) 63 (78.8) 5 (6.3) 2 (2.5) 67 (83.8) 11 (13.8) 72 (90) 23 (28.8) 2 (2.5) 8 (10) 14 (17.5) 6 (7.5) 34 (42.5) 11 (9.2) 15 58 15 54 32 20
(19) (72.5) (19) (67.5) (40) (25)
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Invitations to the study included a one-time anonymous link to direct participants to the survey. Participants then read an information sheet stating their participation is voluntarily and that the study could be exited at any time. Individuals were also informed that accessing the link equated to their consent to participate. Additionally, participants were informed that responses would be reported in the aggregate with the exception of open-ended items, for which individual answers would be de-identified as needed to maintain confidentiality. The study was granted exempt status by the university's Institutional Review Board (IRB). Statistical analysis Qualtrics® (Provo, UT, USA) was utilized to gather participant responses on demographics and for the OES. Responses were exported from Qualtrics® into a Microsoft Excel workbook and then entered into SPSS Statistics 21.0 (IBM Corp, Armonk, NY) for data analyses. All data files were managed by the principal investigator and statistician. Data obtained were quantitative and qualitative. Descriptive statistics were determined from the quantitative data. Additionally, variables were entered into a regression model to test several predictive relationships related to matching to a PGY-2 residency in oncology, perceptions of preparedness, exposure, and support. For qualitative measures, each free response question allowed for the identification of emerging themes among participants' responses. The researchers utilized a thematic analysis approach to identify emerging themes and develop a coding scheme for openended responses.12 After examining each set of responses per individual item, emerging categories were noted (i.e. didactics as a theme from recommendations for PharmD curricula). A list of approximately three to five categories per question was constructed, after which each response was coded. Themes qualified as an individual category if a minimum of 5% of total responses was met. Results One hundred and two individuals responded to the survey link. Twenty-two participants were excluded (10 did not meet inclusion criteria, 12 did not complete a majority of the survey items). As a result, a total of 80 participants were included in the final analyses. Demographics (Table 2) Of the 80 survey participants, 52 (65%) identified as female. The average reported age was approximately 39 years (M = 39.18; SD = 10.55). The majority of participants (n = 63; 78.8%) identified as White, and the majority of participants (n = 67; 83.8%) identified as not of Hispanic or Latino origin. Of the 80 total participants, 72 (90%) reported having earned a PharmD, 62 (77.5%) reported having received some form of post-graduate training, 61 (76.3%) reported being board certified in oncology (i.e. BoardCertified Oncology Pharmacist) alone or in conjunction with other board certifications. Additionally, 14 (17.5%) reported having obtained a PGY-1 as their sole form of post-graduate training, while 34 (42.5%) reported having obtained both PGY-1 and PGY-2 training, and six (7.5%) participants reported PGY-2 training alone. Regarding practice setting, 58 (72.5%) participants reported the outpatient oncology setting formed either all or a component of their practice area. For the inpatient setting, 54 (67.5%) participants stated this practice setting constituted either all or a component of their clinical practice. A total of 32 (40%) participants reported that an infusion center compromised either the entirety or a component of their practice setting. Academia was reported as a component of the practice setting for 20 (25%) participants. Predictors of the pursuit of a PGY-2 residency in oncology When examining the factors that influence the individual's decision to pursue a PGY-2 residency in oncology, we evaluated the number of oncology APPEs, degree of preparedness and interest from didactic lectures or experiential training (i.e. APPEs), and whether an impactful moment related to oncology would be associated with the pursuit of a PGY-2 residency in oncology. After controlling for variance due to individual differences (i.e. age, sex, race, years of practice), for the 95% of the respondents who reported at least completing one APPE in oncology, the number of APPE oncology rotations reported by the participant was associated with the completion of a PGY-2 residency in oncology (p = .047). Namely, those without an APPE in oncology pursued a PGY2 residency in oncology 22.6% of the time, whereas those with one or two APPEs in oncology pursued this residency training 67.6% and 72.7% of the time, respectively. Also, participants' perceived level of preparedness from didactic oncology training correlated with the pursuit of a PGY-2 residency in oncology (p = .002). In contrast, the degree to which didactic oncology training increased the respondent's interest in oncology was not a statistically significant predictor of the pursuit of oncology residency training. Additionally, having an impactful moment instrumental in the decision to pursue oncology did not predict the pursuit of PGY-2 oncology training. Finally, the respondents' reported experience receiving mentorship in oncology also did not predict whether the individual pursued a PGY-2 residency in oncology. Free response Based on the qualitative analysis, three predominant themes emerged regarding participants' descriptions of aspects of the didactic curriculum that increased their sense of preparedness for their current oncology pharmacy position. These included chemotherapeutics and toxicities, disease state approach to oncology instruction, and supportive care lectures. For example, one participant noted that the approach to teaching oncology through the “supportive care lens” allowed the material to be applicable to all practice settings. 1208
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Participants' descriptions of aspects of the experiential education program that increased their sense of preparedness resulted in the salient themes of preceptors, application of knowledge, variety of and oncology specific rotations, multidisciplinary opportunities, and patient counseling. One participant remarked that “working with multidisciplinary teams who relied heavily on their pharmacists” increased their level of preparedness, emphasizing the impact of interprofessional approaches to care. Also related to multidisciplinary approaches, one participant enthusiastically reported that “tumor board helped me to connect all the pieces the patient endures.” The responses regarding the aspects of post-graduate training that prepared participants for their oncology careers elucidated the themes related to aspects of PGY-1 and PGY-2 training, preceptor support, and multidisciplinary opportunities. Specifically related to PGY-1 training, one participant shared their experience of having “two rotations in oncology as a PGY-1” and completing “an MUE on an oncology topic” increased their sense of preparedness for a career in oncology. The reports of an impactful experience in oncology delineated three emerging themes of personal experience, interest in the oncology field, and a professional request or opportunity. Personal experiences enveloped either individual or close family or friend experiences with a cancer diagnosis. Additionally, one respondent noted that “hav[ing] been affected by a chronic disease” increased their desire “to work with patients…dealing with chronic illness.” An innate interest in the field encompassed aspects such as volunteering in an oncology setting or reading an impactful book on the topic. Finally, professional requests involved an outside individual presenting the participant with an opportunity to pursue oncology in some form, for example, when a “new cancer center was being built.” The responses regarding the experiences of significant support in the pursuit of a career in oncology highlighted the effect of professional influence, such as with preceptors, colleagues, or mentors who “fostered interest and curiosity.” Another source of support was management, as evidenced by one participant who noted that “my director of pharmacy gave me free rein to learn what I needed as well as many opportunities to enhance my practice.” The experiences regarding setbacks, obstacles, and challenges reported by participants generated a myriad of diverse categories including issues with post-graduate training, feelings of unpreparedness, bureaucratic challenges, a personal event or circumstance, challenges with the oncology field itself, or the receipt of negative feedback. One participant shared “despite wanting to pursue a PGY-2 residency in oncology and applying to multiple programs, I was not invited for an onsite interview.” Another revealed the challenge of having to remove themselves from a “PGY-2 oncology residency halfway through.” Yet another participant succinctly reported their main obstacle as “lack of mentorship.” For those participants that currently mentored students or residents, the descriptions of activities or strategies they engage in elucidated categories of developing rotation activities, serving as official preceptors or RPDs, conducting individualized conversations, and involvement in projects/research. One participant shared an activity they employ as a preceptor that includes encouraging the student to “counsel patients on supportive care so that even if [the student goes] into another area of pharmacy, they understand how chemotherapy affects the body, and they reach out to patients…undergoing treatment to provide them with all the support they can.” Participants provided recommendations for PharmD curricula that could be categorized into didactic and experiential recommendations, as well as specifically for interprofessional education, oncology career exposure, an oncology elective, and use of additional patient cases. Regarding didactics, one participant stated that “the oncology portion in the pharmacy didactic curriculum MUST be increased,” while another felt that pharmacy schools should “require [an] oncology APPE.” Still another stated that schools “need to increase general offerings and when possible offer oncology as an elective to go more in-depth.” Discussion Identifying factors related to career preparedness, exposure, and support The OES elucidated important potential relationships among factors that relate to the interest, preparedness, and exposure of currently practicing oncology pharmacists. Results indicate the number of oncology APPEs is related to the decision to pursue PGY-2 oncology residency training. Thus, in schools where students have the opportunity to experience such APPE training, these students may have had increased exposure to the oncology field, ultimately leading to their decision to pursue advanced oncology training. This finding highlights the opportunity for offices of experiential education to further explore and offer a wider variety of oncology APPEs for students to explore the field in a supportive learning environment. Alternatively, if the establishment or broadening of oncology APPEs is not feasible, identifying core APPEs with an oncology focus (e.g., ambulatory care with oncology supportive services) may provide an avenue for student exposure to the field. In addition, schools and colleges can also find creative and strategic ways to incorporate oncology experiences within introductory pharmacy practice experiences (IPPEs). For example, certain hours in community or hospital IPPE experiences can be tied to the provision of care for oncology patients. Furthermore, this result suggests students with even a small interest in oncology should take advantage of these opportunities to ensure they are competitive candidates should they further pursue their candidacy as PGY-2 oncology residents. As the didactic component of the participant's PharmD curriculum increased the perceived sense of preparedness, the participant was more likely to pursue a PGY-2 residency in oncology, underscoring the potential positive impact a strong oncology component in the curriculum can have on the learner. Interestingly, the degree to which the didactic curriculum increased the participant's interest did not correlate with this decision. Rather, this survey showed that the sense of preparedness was more closely related to the pursuit of advanced training. 1209
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Mentorship While it was not found that mentorship in oncology predicted the likelihood of pursuing PGY-2 oncology residency training, it is possible that currently practicing oncology pharmacists found a mentor during their PGY-2 training or in their first position as a practicing pharmacist. Indeed, “preceptors and mentors” was found to be a salient category from the open-ended question regarding significant support received in the pursuit of a career in oncology. Furthermore, while having had a mentor in the pursuit of oncology did not predict the likelihood of the practitioner currently serving as a mentor, this may underscore the fact that formal mentorship as a targeted focus in pharmacy education is a relatively recent concept.13 Thus, currently practicing oncology pharmacists may serve as mentors even without having received direct mentorship themselves prior to entering into oncology. In addition, it is possible that practitioners may serve as preceptors or co-preceptors without considering this contribution as direct mentorship. Strategies to improve PharmD curricula In addition, participants shared a multitude of ideas and strategies that can be utilized by stakeholders in US pharmacy education with regard to the oncology curriculum. Participants stressed that their oncology curriculum was insufficient or did not align with current demands of practice as related to job responsibilities. Stakeholders in pharmacy curricula may find it fruitful to evaluate their current approaches to oncology education in the PharmD program to ensure this didactic piece achieves its objectives. The results of a previous study showed a wide range in the number of didactic hours.9 Therefore, it is unknown if there is a “minimum” required number of hours which will allow for a student to feel competent. Regardless, it is not feasible to expect the didactic component of the curriculum to fully prepare student pharmacists for oncology practice. Notably, ACCP Pharmacotherapy Didactic Curriculum Toolkit designates all oncology topics as tier two, signifying that graduates may receive didactic training in the topic but additional training is likely necessary to equip the practitioner with the skills necessary for direct patient care.14 Participants noted that experiential education is a potential avenue through which students could gain more exposure to the field of oncology; more IPPE and APPE opportunities may serve as a method to increase their comfort potentially leading to postgraduate training opportunities. There has been recent debate about the designation of oncology topics as tier two by ACCP. Discussion on the changes in the tier has resulted from the increase in cancer survivors and oral anticancer agents. The five-year survival rate for cancers diagnosed from 2009 to 2015 is currently 67.1%, which is higher than the survival rate of 49% for 1975–1977.15,16 The increased survival rate can be attributed, in part, to new chemotherapeutic agents, many of which are oral targeted therapies dispensed by community pharmacists. The Hematology/Oncology Pharmacy Association (HOPA) reviewed the 2016 ACCP Pharmacotherapy Didactic Curriculum Toolkit and disagreed that certain oncologic disorders should be classified as tier two.17 The HOPA recommended that breast cancer, colon cancer, lung cancer, prostate cancer, support care, oncologic emergencies, infections in the immunocompromised host (neutropenic fever), and oncology dosing and calculations be considered a tier one.17 The 2016 ACCP Educational Affairs Committee did not support the HOPA viewpoint, except for the recommendation for oncology dosing and calculations as tier one.18 Two studies, one in Canada and another in Japan, found a low rate of positive response concerning education in oncology and about oral chemotherapy.19,20 Both surveys demonstrate a need for additional education in oncology. A recent study evaluated the impact of an oncology simulation at a US pharmacy school by utilizing stations to incorporate order set completion, patient counseling, order verification, and aseptic technique.21 Results from the pre- and post-simulation assessments demonstrated a statistically significant increase in knowledge in three of the six constructs. Perceptions of pharmacist roles as well as self-confidence in the ability to prepare a regimen increased. This strategy, utilizing an ovarian cancer patient case, incorporates several of the recommendations made by participants in the present study. Notably, the simulation incorporates various aspects of oncology pharmacy practice into one event, all of which increase exposure to the oncology field. In addition, the use of a patient case, recommended by participants, allows application of learned material from the classroom to occur shortly after the delivery of the lecture. Finally, the authors described the potential to enhance the simulation by expanding it as an interprofessional education opportunity, thereby incorporating yet another emerging theme from the OES. Incorporating data available from the OES, there are many opportunities to improve PharmD curricula as it relates to oncology practice. One such recommendation involves an evaluation of each school's approach to oncology didactic teaching by outlining the objectives to achieve and utilizing assessment data to ascertain the program's success. While it is not likely critical to recommend a specific number of hours, topics covered should align with the ACCP Toolkit in order to ensure uniformity among PharmD curricula.14 With regard to experiential education, the authors of the present work recommend that each PharmD program offer an opportunity of an oncology APPE as an elective experience at a minimum. As resources allow, it may best serve the next generation of pharmacists to have a required advanced rotation in oncology in order to ensure exposure to the needs of the growing population of cancer survivors. Additionally, opportunities to grow the current postgraduate training offerings for pharmacy graduates should be assessed. In 2018, there were 168 PGY-2 oncology residency positions available in 97 programs in the ASHP pharmacy residency match process.22 A total of 59 positions were filled with an early commitment, leaving 109 open positions for the match. Onehundred percent of these positions were filled in the first phase of the match, suggesting that PGY-2 oncology pharmacy residency programs are in high demand and additional post-graduate training programs are warranted. There were several limitations to the present study. As the survey was available in online forums, there exists the possibility of not reaching intended participants. Similarly, there is no opportunity to assess the actual response rate given the wide availability of the survey (i.e. the survey was distributed to oncology practitioners and directors who then distributed the survey to potential participants). However, the survey completion rate (calculated by dividing the number of surveys completed by the number of surveys started by respondents) was 79.4%. Another limitation of this survey instrument was that it has not been previously validated and is 1210
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largely exploratory. More detailed background of the participants' experiences (i.e. the specific curricular requirements at their respective pharmacy programs) was not assessed. It is important to note that not all colleges offer an APPE in oncology nor can every student participate in one if desired due to rotation space limitations. Similarly, not every PGY-1 residency offers an elective oncology rotation. Finally, this survey only explores training as it relates to preparedness, exposure, and support for oncology practice; it does not explore other pharmacy specialties of interest to students (e.g., psychiatry, pediatrics) which may reveal differing results. For example, the ACCP Pediatrics PRN has published recommendations for PharmD curricula providing specific didactic hour recommendations, urging a required clinical rotation in pediatrics, and a changing attitude to acknowledge the ubiquity of pediatric pharmacy practice.23 Oncology pharmacy practice may benefit from similar guidance by stakeholders. The OES provides needed insight into the potential opportunities specific to oncology pharmacy education. One of the objectives of this study was to assess factors that predict pursuit of a PGY-2 oncology residency. The foundation of a PGY-2 specialty residency is the PharmD degree and a PGY-1 residency. The researchers did not directly ask the participants how their PGY1 residency impacted their pursuit of a PGY-2 oncology residency, which is a limitation of the study, but participants were asked how post-graduate training generally prepared them for their current position in oncology. Another limitation of this study is the limited exposure of student pharmacists to practicing oncology pharmacists within their didactic and experiential experiences, which could result in a limited ability of participants to provide information on how their PharmD program influenced their career in oncology. In a 2012 survey, Newton et al. found that 103 instructors taught oncology pharmacotherapy across 116 schools and colleges of pharmacy. Adjunct faculty or guest lecturers were used by 43% and about 15% of programs used faculty who did not practice in oncology.8 The 2016 Accreditation Council for Pharmacy Education Standards do not require student pharmacists to have an oncology APPE rotation (ACPE Standards) and most schools offer oncology as an elective rotation.18,24 In the survey by Newton et al., of 116 schools and colleges of pharmacy, most offered one or more oncology APPEs, but the researcher did not indicate what percentage of students actually completed such a rotation. Older schools and colleges of pharmacy (established longer than seven years) tended to provide more diversity in their APPE oncology rotation offerings.8 In a more recent 2015 survey of 62 schools of pharmacy, most schools (73%) offered fewer than 30 oncology APPE rotations and a median of 15% of students actually took an oncology APPE each year.9 Finally, a limitation to the survey included the potential for bias related to outside potential exposures to oncology. These exposures may have occurred before enrollment in a PharmD program or oncology APPE or residency. This limitation was mitigated by the ability of the respondent to provide information in the open-ended responses to share important events or experiences that may have ignited their interest in the field of oncology (i.e. cancer diagnosis in the family). Conclusion In this national survey of currently practicing US oncology pharmacists, several elements regarding practice preparedness, exposure, and support were elucidated. Namely, it was found that APPEs in oncology, as well as the degree to which didactic curriculum in oncology prepared the learner, were significant predictors of the pursuit of a PGY-2 in oncology pharmacy. A multitude of opportunities for development of PharmD curricula with respect to oncology are possible with these findings. While not every student pharmacist will pursue oncology, it is important to recognize that many, if not most, of those on the cusp of beginning their pharmacy careers will contribute to the care of the growing number of cancer survivors in the US. Thus, it is critical to elucidate strategies to ensure that not only are these students prepared, but also that they feel equipped to engage in their own endeavors of self-teaching and life-long learning, especially given the fast-changing nature of cancer care. Further studies could explore how specific aspects of the didactic curriculum impact the level of preparedness of the pharmacy student (e.g., through topics covered, case studies, or interprofessional opportunities.) Also, studies examining which elements allow a student pharmacist to feel prepared to independently seek further training in oncology are needed. Finally, additional research could examine the perceptions of RPDs of oncology programs regarding candidate preparedness. Disclosures The authors have no financial disclosures to report Declaration of competing interest The authors have no conflicts of interest to report. References 1. Hematology/Oncology (Cancer) Approvals & Safety Notifications. US Food and Drug Administration. https://www.fda.gov/drugs/resources-informationapproved-drugs/hematologyoncology-cancer-approvals-safety-notifications. Published 8 August 2019. Accessed 7 September 2019. 2. The state of cancer care in America, 2017. A report by the American Society of Clinical Oncology. J Oncol Pract. 2017;13(4):e353–e394. https://doi.org/10.1200/ JOP.2016.02074. 3. Miller KD, Siegel RL, Lin CC, et al. Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin. 2016;66(4):271–289. 4. Rooney JE, Ponushis A. A giant leap toward combating cancer. Academic Pharmacy Now. 2017;10(2):10–16. 5. Cavallo J. Who will care for patients with cancer? The confluence of looming oncology workforce shortages just as demand for cancer care explodes has experts searching for solutions. The ASCO Post. http://www.ascopost.com/issues/august-15-2014/who-will-care-for-patients-with-cancer/. Published 15 August 2014.
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Accessed 7 September 2019. 6. Sessions JK, Valgus J, Barbour SY, Iacovelli L. Role of oncology clinical pharmacists in light of the oncology workforce study. J Oncol Pract. 2010;6(5):270–272. 7. Anderson C, Plevin DM, McKinnon RA. Educating our students about pharmaceutical care for those living with cancer. Am J Pharm Educ. 2012;76(7) https://doi. org/10.5688/ajpe767119. 8. Newton MD, Schwinghammer TL, Green MR. Comments on “Educating our students about pharmaceutical care for those living with cancer”. Am J Pharm Educ. 2012;76(9) https://doi.org/10.5688/ajpe769181. 9. Kwon J, Ledvina D, Newton M, Green MR, Ignoffo R. Oncology pharmacy education and training in the United States Schools of Pharmacy. Curr Pharm Teach Learn. 2015;7(4):451–457. 10. May P, Ladd J. Florida pharmacy students’ perspectives on careers in oncology. J Hematol Oncol Pharm. 2017;7(2):69–75. 11. Saylor MS, Blanchette LM, Smith MB, Cambron K, Andricopulos K, Brown MJ. Initiation and preliminary evaluation of an oncology pharmacy training course for staff pharmacists. J Oncol Pharm Pract. 2016;22(4):611–617. 12. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 13. Waghel RC, Wilson JA, Battise DM, Frye J. Reflections on a year-long student and pharmacist paired mentorship program. Curr Pharm Teach Learn. 2017;9(4):713–718. 14. American College of Clinical Pharmacy, Schwinghammer TL, Crannage AJ, et al. ACCP pharmacotherapy didactic curriculum toolkit. https://www.accp.com/ docs/positions/misc/Toolkit_final.pdf; 2016. 15. Cancer stat facts: cancer of any site. National Cancer Institute. Surveillance, epidemiology, and end results program. https://seer.cancer.gov/statfacts/html/all. html, Accessed 7 September 2019. 16. Anderson C, Plevin DM, McKinnon FA. Educating our students about pharmaceutical care f or those living with cancer. Am J Pharm Educ. 2012;76(7) https://doi. org/10.5688/ajpe767119. 17. Nightingale G, Saunders IM, Comeau JM, et al. Hematology/oncology pharmacy association entry-level competencies task force response statement to the 2016 American college of clinical pharmacy pharmacotherapy didactic curriculum toolkit. Pharmacotherapy. 2017;37(5):e30–e31. https://doi.org/10.1002/phar.1919. 18. Schwinghammer TL, Hammond DA, Crannage AJ. Reply to the hematology/oncology pharmacy association alternative viewpoint on the 2016 ACCP pharmacotherapy didactic curriculum toolkit. Pharmacotherapy. 2017;37(8):e93–e95. https://doi.org/10.1002/phar.1967. 19. Abbott R, Edwards S, Whelan M, Edwards J, Dranitsaris G. Are community pharmacists equipped to ensure the safe use of oral anticancer therapy in the community setting? Results of a cross-country survey of community pharmacists in Canada. J Oncol Pharm Pract. 2014;20(1):29–39. 20. Suzuki S, Abbot R, Sakurai H, et al. Evaluation of community pharmacist ability to ensure the safe use of oral anticancer agents: a nationwide survey in Japan evaluate whether community pharmacists felt comfortable to ensure safe use of oral anticancer agents. Jpn J Clin Oncol. 2017;47(5):413–421. 21. Serag-Bolos ES, Chudow M, Perkins J, Patel RV. Enhancing student knowledge through a comprehensive oncology simulation. Am J Pharm Educ. 2018;82(3) https://doi.org/10.5688/ajpe6245. 22. American Society of Health-System Pharmacists Resident Matching Program. Summary of programs and positions offered and filled in the 2018 match combined phase I and phase II. https://natmatch.com/ashprmp/stats/2018summpos.pdf. Published 2018. Accessed 7 September 2019. 23. Aucoin RG, Buck ML, Dupuis LL, Dominguez KD, Smith KP. Pediatric pharmacotherapeutic education: current status and recommendations to fill the growing need. Pharmacotherapy. 2005;25(9):1277–1282. 24. Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree. 2015. https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Published 2016. Accessed 7 September 2019.
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Currents in Pharmacy Teaching and Learning journal homepage: www.elsevier.com/locate/cptl
Research Paper
Identifying opportunities for PharmD curricular reform by surveying oncology pharmacists about career preparedness and exposure
T
Sara A. Thompsona, Margie E. Padillab, , Amanda M. Loyab, Mary L. Chavezb, Jessica Shenberger-Trujillob ⁎
a b
North Dakota State University School of Pharmacy, NDSU Dept. 2650 / PO Box 6050 / Fargo, ND 58108-6050, United States The University of Texas at El Paso School of Pharmacy, 500 W. University, El Paso, TX 79968, United States
ARTICLE INFO
ABSTRACT
Keywords: Oncology Curriculum Preparedness Mentorship
Introduction: The primary objective of the study was to assess factors that predict pursuit of an oncology post-graduate year 2 (PGY-2) residency. Additional objectives included identifying the role of and exploring opportunities for PharmD curricula to increase student interest in the oncology field. Methods: An anonymous 15-minute survey was developed and administered to oncology pharmacists and residents. Study participants were included if they were actively practicing as clinical pharmacists in an oncology setting in the US, maintained an active pharmacist license, and > 18 years of age. Responses were analyzed using descriptive and inferential statistics. All results are reported in aggregate, with the exception of quotes obtained from open-ended responses. Results: Eighty participants were included in analyses. After controlling for variance due to age, sex, race, years of practice, the number of oncology advanced pharmacy practice experiences (APPEs) correlated with pursuit of a PGY-2 residency in oncology (p = 0.047). Additionally, participants' perceived level of preparedness from didactic oncology training predicted pursuit of an oncology PGY-2 residency (p = 0.002). Emerging themes in pursuing oncology from openended items revealed that inclusion of supportive care in the didactic curriculum and having a family member or friend diagnosed with cancer were important factors. Additionally, participants' responses regarding PharmD curricula included recommendations to inform didactic and experiential education. Conclusions: The results support the need for reevaluation of oncology education in PharmD curricula. Further studies could explore specific aspects of didactic curriculum that impact the level of student preparedness, and which elements encourage a student pharmacist to seek further training in the oncology field.
Introduction The field of oncology has experienced an increase in treatment options with 16 new drug approvals in 2017 alone, in addition to the first agent to receive approval based on a tumor's biomarker and not the origination site.1 This ever-growing armamentarium has Corresponding author. E-mail addresses: [email protected] (S.A. Thompson), [email protected] (M.E. Padilla), [email protected] (A.M. Loya), [email protected] (M.L. Chavez), [email protected] (J. Shenberger-Trujillo). ⁎
https://doi.org/10.1016/j.cptl.2019.09.002
1877-1297/ © 2019 Elsevier Inc. All rights reserved.
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led to complex regimens and more involvement between interdisciplinary health care providers to provide optimal care. As a result, there is a growing need for oncology trained healthcare professionals. An American Society of Clinical Oncology (ASCO) report determined that over 12,000 oncologists and hematologists provided care to cancer patients in 2016.2 Approximately 20% of practicing oncologists are older than 64 years and nearing retirement, with some geographic regions reporting insufficient younger oncologists entering the field. Reasons for this impending shortage are multifaceted and include retirement, increased demand for practitioners as the population ages, and burnout. As the population ages, in combination with better survival outcomes for many malignancies, the number of cancer survivors will increase. It is projected the number of cancer survivors will reach 20 million in the United States (US) by 2026.3 Additionally, the Cancer Moonshot Initiative aims to focus on the prevention and treatment of malignancy via a multitude of initiatives and interdisciplinary relationships (e.g., pharmacists, physician assistants, nurses). Former Vice President Joe Biden reinforced these objectives at the 2016 ASCO meeting.4 A solution proposed by the ASCO Chief Medical Officer Richard L. Schilsky is the incorporation of advanced practice providers into offices and clinics that provide care to cancer patients.5 This newly expanded workforce could include highly-trained clinical pharmacists.6 Clinical pharmacists are called upon to contribute to the care of oncology patients. The concern of how to approach training in the PharmD curriculum with respect to oncology has been recently posited.7 Therapeutic factors, such as drug therapies in oncology that increase in both number and complexity, increasing cost of therapy, as well as the flourishing field of cancer survivorship, have implications to the pharmacist's contributory role and responsibility. Newton and colleagues contend it is no longer sufficient to consider the care of oncology patients solely the responsibility of specialty trained pharmacists.8 Rather, any pharmacist may be called upon to interact with oncology patients from initial diagnosis to end-of-life care as necessary. This potential role signifies a need to prepare future pharmacists to care for the oncology patient in a variety of practice settings. The growing need for pharmacists to care for the cancer patient in a multitude of settings necessitates an evaluation of PharmD curricula with respect to oncology training. One recent study surveyed chairs of clinical pharmacy practice departments in all US pharmacy programs in 2013.9 Of the schools/colleges that responded (47% of those surveyed), department chairs reported a wide range in the number of contact hours dedicated to oncology topics in the didactic curriculum (i.e. 1–85 hours). Experiential education opportunities in oncology were also available but demand for placements in oncology advanced pharmacy practice experiences (APPEs) was low. Though limited by response rate, the findings of this study elucidate potential opportunities in PharmD curricula, such as reevaluation of the oncology component of the curriculum and increased exposure to experiential oncology opportunities. Other studies have specifically explored pharmacy student interests in oncology as well as oncology training opportunities for pharmacists already in practice.10,11 Data from investigations into pharmacy student interests have revealed that despite an interest in the field, many students have a lack of comfort with and knowledge of oncology.10 Post-graduate formal training opportunities in oncology have shown to be promising by increasing the oncology knowledge of pharmacists; however, results are limited by high drop-out rates, small sample sizes, and the unlikely prospect of pharmacists prioritizing these training opportunities while completing job responsibilities.11 These studies suggest that formal instruction in the PharmD curriculum and residency training would the best approach to adequately prepare pharmacists to practice in this field. However, at this time it appears no study has specifically examined the preparedness, exposure, and training received by pharmacists prior to practicing as clinical pharmacists in the oncology setting. The primary objective of this study is to assess factors that impact the pursuit of a post-graduate year two (PGY-2) residency in oncology, with additional objectives of identifying and exploring strategies in PharmD curricula to increase student interest in the oncology field. This study aims to stimulate discussion among pharmacy programs regarding best practices in the development of a curriculum that may optimally prepare student pharmacists to serve oncology patients. Methods The current study was conducted by researchers at a university in the southwest region of the US. A survey was developed to assess various elements of practice preparedness, exposure and support related to oncology pharmacy (Table 1). The survey consisted of a demographic section, which included items regarding age, gender, highest degree earned, training completed, credentials, and practice area. This was followed by a more detailed inquiry of participants' personal experiences related to their trajectory as oncology pharmacists. This latter portion of the survey was called the Oncology Experience Survey (OES). The OES contained 24-items in total (dependent on certain answers to skip-logic questions in which topics that were not applicable to the individual such as residency experiences were skipped) and was estimated to require 15 min to complete. The OES focused on factors that support or discourage pursuit of a career in oncology pharmacy. A total of 13 questions were assessed for quantitative analysis of results (i.e. Likert scale response options raged from a value of 1 to 5), while 11 items were included for qualitative analysis (i.e. open ended items). Sample items include training that increased interest, instrumental support in preparation for a career in oncology, and mentorship. Open-ended questions also included recommendations for PharmD and resident learners. Prior to commencement of data collection, the survey was pretested by a small cohort of oncology pharmacists (n = 3) to provide feedback for improvement of the survey. Minor adjustments were made as a result of recommendations (e.g., grammar) from the pretest population. Study participants were included if they were actively practicing US clinical pharmacists in the oncology setting, had an active pharmacist license, and were at least 18 years of age. Thus, participants reflect a national sample of pharmacy practitioners. Individuals who do not practice in oncology, nor have an active pharmacist license, were post-graduate year 1 (PGY-1) residents at the time of the survey, or participants with incomplete responses (< 50%) were excluded. Current practicing oncology pharmacists were recruited via several means. Current post-graduate year 2 (PGY-2) oncology 1206
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Table 1 Sample items from the Oncology Experience Survey (OES).a To To To To To To
what what what what what what
extent extent extent extent extent extent
do do do do do do
you you you you you you
feel feel feel feel feel feel
your your your your your your
didactic oncology curriculum prepared you for your current position in oncology? didactic oncology curriculum increased your interest in pursuing oncology? experiential oncology curriculum prepared you for your current position in oncology? experiential oncology curriculum increased your interest in pursuing oncology? post-graduate training prepared you for your current position in oncology? post-graduate training increased your interest in pursuing oncology?
Open-ended items If there were specific components of the didactic curriculum that prepared you, please describe If there were specific components of the experiential curriculum that prepared you, please describe If there were specific components of your post-graduate training that prepared you, please describe What recommendations do you have for oncology training in PharmD programs? Please consider recommendations for the a) didactic curriculum, b) experiential curriculum, and c) for co-curriculum or interprofessional education. What recommendations do you have for resident learners? Other items What experience in oncology did you have in advanced pharmacy practice experiences (APPEs)? Did you pursue a post-graduate year 2 (PGY-2) residency in oncology? Was there an impactful personal experience or event that was instrumental in your decision to pursue oncology? Did you experience significant support in your pursuit of a career in oncology? Did you experience setbacks, challenges, or obstacles in your pursuit of a career in oncology? Did you have a mentor who encouraged you in oncology? Do you currently mentor students interested in oncology? a
Likert type item response options varied from a value of 1 to 5.
pharmacy residency program directors (RPDs) were identified via contact information from the American Society of Health-System Pharmacists (ASHP) residency directory. Additionally, an announcement was sent to the Hematology/Oncology network group of the American College of Clinical Pharmacy (ACCP). Participants were also encouraged to share the survey with interested oncology pharmacy colleagues and residents. Table 2 Demographics. n (%) Age in years (n = 78) (SD) Gender - N (%) Male Female Race - N (%) American Indian/Alaskan Native Asian/Asian American African American/Black Native Hawaiian/Pacific Islander White/Caucasian Other Hispanic/Latino - N (%) Yes No No answer Board certification N (%) BCOP (alone or in combination) BCPS (alone or in combination) BCACP (in combination) None Post-graduate training (%) PGY1 residency PGY-2 residency PGY1 and 2 residencies Years in practice (SD) Practice setting (%) Outpatient Outpatient and other settings Inpatient Inpatient and other settings Infusion center (alone or in combination) Academia (in combination)
PGY1 = post-graduate year 1; PGY2 = post-graduate year 2. 1207
39 (10) 28 (35) 52 (65) 1 (1.3) 10 (12.5) 0 (0) 1 (1.3) 63 (78.8) 5 (6.3) 2 (2.5) 67 (83.8) 11 (13.8) 72 (90) 23 (28.8) 2 (2.5) 8 (10) 14 (17.5) 6 (7.5) 34 (42.5) 11 (9.2) 15 58 15 54 32 20
(19) (72.5) (19) (67.5) (40) (25)
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Invitations to the study included a one-time anonymous link to direct participants to the survey. Participants then read an information sheet stating their participation is voluntarily and that the study could be exited at any time. Individuals were also informed that accessing the link equated to their consent to participate. Additionally, participants were informed that responses would be reported in the aggregate with the exception of open-ended items, for which individual answers would be de-identified as needed to maintain confidentiality. The study was granted exempt status by the university's Institutional Review Board (IRB). Statistical analysis Qualtrics® (Provo, UT, USA) was utilized to gather participant responses on demographics and for the OES. Responses were exported from Qualtrics® into a Microsoft Excel workbook and then entered into SPSS Statistics 21.0 (IBM Corp, Armonk, NY) for data analyses. All data files were managed by the principal investigator and statistician. Data obtained were quantitative and qualitative. Descriptive statistics were determined from the quantitative data. Additionally, variables were entered into a regression model to test several predictive relationships related to matching to a PGY-2 residency in oncology, perceptions of preparedness, exposure, and support. For qualitative measures, each free response question allowed for the identification of emerging themes among participants' responses. The researchers utilized a thematic analysis approach to identify emerging themes and develop a coding scheme for openended responses.12 After examining each set of responses per individual item, emerging categories were noted (i.e. didactics as a theme from recommendations for PharmD curricula). A list of approximately three to five categories per question was constructed, after which each response was coded. Themes qualified as an individual category if a minimum of 5% of total responses was met. Results One hundred and two individuals responded to the survey link. Twenty-two participants were excluded (10 did not meet inclusion criteria, 12 did not complete a majority of the survey items). As a result, a total of 80 participants were included in the final analyses. Demographics (Table 2) Of the 80 survey participants, 52 (65%) identified as female. The average reported age was approximately 39 years (M = 39.18; SD = 10.55). The majority of participants (n = 63; 78.8%) identified as White, and the majority of participants (n = 67; 83.8%) identified as not of Hispanic or Latino origin. Of the 80 total participants, 72 (90%) reported having earned a PharmD, 62 (77.5%) reported having received some form of post-graduate training, 61 (76.3%) reported being board certified in oncology (i.e. BoardCertified Oncology Pharmacist) alone or in conjunction with other board certifications. Additionally, 14 (17.5%) reported having obtained a PGY-1 as their sole form of post-graduate training, while 34 (42.5%) reported having obtained both PGY-1 and PGY-2 training, and six (7.5%) participants reported PGY-2 training alone. Regarding practice setting, 58 (72.5%) participants reported the outpatient oncology setting formed either all or a component of their practice area. For the inpatient setting, 54 (67.5%) participants stated this practice setting constituted either all or a component of their clinical practice. A total of 32 (40%) participants reported that an infusion center compromised either the entirety or a component of their practice setting. Academia was reported as a component of the practice setting for 20 (25%) participants. Predictors of the pursuit of a PGY-2 residency in oncology When examining the factors that influence the individual's decision to pursue a PGY-2 residency in oncology, we evaluated the number of oncology APPEs, degree of preparedness and interest from didactic lectures or experiential training (i.e. APPEs), and whether an impactful moment related to oncology would be associated with the pursuit of a PGY-2 residency in oncology. After controlling for variance due to individual differences (i.e. age, sex, race, years of practice), for the 95% of the respondents who reported at least completing one APPE in oncology, the number of APPE oncology rotations reported by the participant was associated with the completion of a PGY-2 residency in oncology (p = .047). Namely, those without an APPE in oncology pursued a PGY2 residency in oncology 22.6% of the time, whereas those with one or two APPEs in oncology pursued this residency training 67.6% and 72.7% of the time, respectively. Also, participants' perceived level of preparedness from didactic oncology training correlated with the pursuit of a PGY-2 residency in oncology (p = .002). In contrast, the degree to which didactic oncology training increased the respondent's interest in oncology was not a statistically significant predictor of the pursuit of oncology residency training. Additionally, having an impactful moment instrumental in the decision to pursue oncology did not predict the pursuit of PGY-2 oncology training. Finally, the respondents' reported experience receiving mentorship in oncology also did not predict whether the individual pursued a PGY-2 residency in oncology. Free response Based on the qualitative analysis, three predominant themes emerged regarding participants' descriptions of aspects of the didactic curriculum that increased their sense of preparedness for their current oncology pharmacy position. These included chemotherapeutics and toxicities, disease state approach to oncology instruction, and supportive care lectures. For example, one participant noted that the approach to teaching oncology through the “supportive care lens” allowed the material to be applicable to all practice settings. 1208
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Participants' descriptions of aspects of the experiential education program that increased their sense of preparedness resulted in the salient themes of preceptors, application of knowledge, variety of and oncology specific rotations, multidisciplinary opportunities, and patient counseling. One participant remarked that “working with multidisciplinary teams who relied heavily on their pharmacists” increased their level of preparedness, emphasizing the impact of interprofessional approaches to care. Also related to multidisciplinary approaches, one participant enthusiastically reported that “tumor board helped me to connect all the pieces the patient endures.” The responses regarding the aspects of post-graduate training that prepared participants for their oncology careers elucidated the themes related to aspects of PGY-1 and PGY-2 training, preceptor support, and multidisciplinary opportunities. Specifically related to PGY-1 training, one participant shared their experience of having “two rotations in oncology as a PGY-1” and completing “an MUE on an oncology topic” increased their sense of preparedness for a career in oncology. The reports of an impactful experience in oncology delineated three emerging themes of personal experience, interest in the oncology field, and a professional request or opportunity. Personal experiences enveloped either individual or close family or friend experiences with a cancer diagnosis. Additionally, one respondent noted that “hav[ing] been affected by a chronic disease” increased their desire “to work with patients…dealing with chronic illness.” An innate interest in the field encompassed aspects such as volunteering in an oncology setting or reading an impactful book on the topic. Finally, professional requests involved an outside individual presenting the participant with an opportunity to pursue oncology in some form, for example, when a “new cancer center was being built.” The responses regarding the experiences of significant support in the pursuit of a career in oncology highlighted the effect of professional influence, such as with preceptors, colleagues, or mentors who “fostered interest and curiosity.” Another source of support was management, as evidenced by one participant who noted that “my director of pharmacy gave me free rein to learn what I needed as well as many opportunities to enhance my practice.” The experiences regarding setbacks, obstacles, and challenges reported by participants generated a myriad of diverse categories including issues with post-graduate training, feelings of unpreparedness, bureaucratic challenges, a personal event or circumstance, challenges with the oncology field itself, or the receipt of negative feedback. One participant shared “despite wanting to pursue a PGY-2 residency in oncology and applying to multiple programs, I was not invited for an onsite interview.” Another revealed the challenge of having to remove themselves from a “PGY-2 oncology residency halfway through.” Yet another participant succinctly reported their main obstacle as “lack of mentorship.” For those participants that currently mentored students or residents, the descriptions of activities or strategies they engage in elucidated categories of developing rotation activities, serving as official preceptors or RPDs, conducting individualized conversations, and involvement in projects/research. One participant shared an activity they employ as a preceptor that includes encouraging the student to “counsel patients on supportive care so that even if [the student goes] into another area of pharmacy, they understand how chemotherapy affects the body, and they reach out to patients…undergoing treatment to provide them with all the support they can.” Participants provided recommendations for PharmD curricula that could be categorized into didactic and experiential recommendations, as well as specifically for interprofessional education, oncology career exposure, an oncology elective, and use of additional patient cases. Regarding didactics, one participant stated that “the oncology portion in the pharmacy didactic curriculum MUST be increased,” while another felt that pharmacy schools should “require [an] oncology APPE.” Still another stated that schools “need to increase general offerings and when possible offer oncology as an elective to go more in-depth.” Discussion Identifying factors related to career preparedness, exposure, and support The OES elucidated important potential relationships among factors that relate to the interest, preparedness, and exposure of currently practicing oncology pharmacists. Results indicate the number of oncology APPEs is related to the decision to pursue PGY-2 oncology residency training. Thus, in schools where students have the opportunity to experience such APPE training, these students may have had increased exposure to the oncology field, ultimately leading to their decision to pursue advanced oncology training. This finding highlights the opportunity for offices of experiential education to further explore and offer a wider variety of oncology APPEs for students to explore the field in a supportive learning environment. Alternatively, if the establishment or broadening of oncology APPEs is not feasible, identifying core APPEs with an oncology focus (e.g., ambulatory care with oncology supportive services) may provide an avenue for student exposure to the field. In addition, schools and colleges can also find creative and strategic ways to incorporate oncology experiences within introductory pharmacy practice experiences (IPPEs). For example, certain hours in community or hospital IPPE experiences can be tied to the provision of care for oncology patients. Furthermore, this result suggests students with even a small interest in oncology should take advantage of these opportunities to ensure they are competitive candidates should they further pursue their candidacy as PGY-2 oncology residents. As the didactic component of the participant's PharmD curriculum increased the perceived sense of preparedness, the participant was more likely to pursue a PGY-2 residency in oncology, underscoring the potential positive impact a strong oncology component in the curriculum can have on the learner. Interestingly, the degree to which the didactic curriculum increased the participant's interest did not correlate with this decision. Rather, this survey showed that the sense of preparedness was more closely related to the pursuit of advanced training. 1209
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Mentorship While it was not found that mentorship in oncology predicted the likelihood of pursuing PGY-2 oncology residency training, it is possible that currently practicing oncology pharmacists found a mentor during their PGY-2 training or in their first position as a practicing pharmacist. Indeed, “preceptors and mentors” was found to be a salient category from the open-ended question regarding significant support received in the pursuit of a career in oncology. Furthermore, while having had a mentor in the pursuit of oncology did not predict the likelihood of the practitioner currently serving as a mentor, this may underscore the fact that formal mentorship as a targeted focus in pharmacy education is a relatively recent concept.13 Thus, currently practicing oncology pharmacists may serve as mentors even without having received direct mentorship themselves prior to entering into oncology. In addition, it is possible that practitioners may serve as preceptors or co-preceptors without considering this contribution as direct mentorship. Strategies to improve PharmD curricula In addition, participants shared a multitude of ideas and strategies that can be utilized by stakeholders in US pharmacy education with regard to the oncology curriculum. Participants stressed that their oncology curriculum was insufficient or did not align with current demands of practice as related to job responsibilities. Stakeholders in pharmacy curricula may find it fruitful to evaluate their current approaches to oncology education in the PharmD program to ensure this didactic piece achieves its objectives. The results of a previous study showed a wide range in the number of didactic hours.9 Therefore, it is unknown if there is a “minimum” required number of hours which will allow for a student to feel competent. Regardless, it is not feasible to expect the didactic component of the curriculum to fully prepare student pharmacists for oncology practice. Notably, ACCP Pharmacotherapy Didactic Curriculum Toolkit designates all oncology topics as tier two, signifying that graduates may receive didactic training in the topic but additional training is likely necessary to equip the practitioner with the skills necessary for direct patient care.14 Participants noted that experiential education is a potential avenue through which students could gain more exposure to the field of oncology; more IPPE and APPE opportunities may serve as a method to increase their comfort potentially leading to postgraduate training opportunities. There has been recent debate about the designation of oncology topics as tier two by ACCP. Discussion on the changes in the tier has resulted from the increase in cancer survivors and oral anticancer agents. The five-year survival rate for cancers diagnosed from 2009 to 2015 is currently 67.1%, which is higher than the survival rate of 49% for 1975–1977.15,16 The increased survival rate can be attributed, in part, to new chemotherapeutic agents, many of which are oral targeted therapies dispensed by community pharmacists. The Hematology/Oncology Pharmacy Association (HOPA) reviewed the 2016 ACCP Pharmacotherapy Didactic Curriculum Toolkit and disagreed that certain oncologic disorders should be classified as tier two.17 The HOPA recommended that breast cancer, colon cancer, lung cancer, prostate cancer, support care, oncologic emergencies, infections in the immunocompromised host (neutropenic fever), and oncology dosing and calculations be considered a tier one.17 The 2016 ACCP Educational Affairs Committee did not support the HOPA viewpoint, except for the recommendation for oncology dosing and calculations as tier one.18 Two studies, one in Canada and another in Japan, found a low rate of positive response concerning education in oncology and about oral chemotherapy.19,20 Both surveys demonstrate a need for additional education in oncology. A recent study evaluated the impact of an oncology simulation at a US pharmacy school by utilizing stations to incorporate order set completion, patient counseling, order verification, and aseptic technique.21 Results from the pre- and post-simulation assessments demonstrated a statistically significant increase in knowledge in three of the six constructs. Perceptions of pharmacist roles as well as self-confidence in the ability to prepare a regimen increased. This strategy, utilizing an ovarian cancer patient case, incorporates several of the recommendations made by participants in the present study. Notably, the simulation incorporates various aspects of oncology pharmacy practice into one event, all of which increase exposure to the oncology field. In addition, the use of a patient case, recommended by participants, allows application of learned material from the classroom to occur shortly after the delivery of the lecture. Finally, the authors described the potential to enhance the simulation by expanding it as an interprofessional education opportunity, thereby incorporating yet another emerging theme from the OES. Incorporating data available from the OES, there are many opportunities to improve PharmD curricula as it relates to oncology practice. One such recommendation involves an evaluation of each school's approach to oncology didactic teaching by outlining the objectives to achieve and utilizing assessment data to ascertain the program's success. While it is not likely critical to recommend a specific number of hours, topics covered should align with the ACCP Toolkit in order to ensure uniformity among PharmD curricula.14 With regard to experiential education, the authors of the present work recommend that each PharmD program offer an opportunity of an oncology APPE as an elective experience at a minimum. As resources allow, it may best serve the next generation of pharmacists to have a required advanced rotation in oncology in order to ensure exposure to the needs of the growing population of cancer survivors. Additionally, opportunities to grow the current postgraduate training offerings for pharmacy graduates should be assessed. In 2018, there were 168 PGY-2 oncology residency positions available in 97 programs in the ASHP pharmacy residency match process.22 A total of 59 positions were filled with an early commitment, leaving 109 open positions for the match. Onehundred percent of these positions were filled in the first phase of the match, suggesting that PGY-2 oncology pharmacy residency programs are in high demand and additional post-graduate training programs are warranted. There were several limitations to the present study. As the survey was available in online forums, there exists the possibility of not reaching intended participants. Similarly, there is no opportunity to assess the actual response rate given the wide availability of the survey (i.e. the survey was distributed to oncology practitioners and directors who then distributed the survey to potential participants). However, the survey completion rate (calculated by dividing the number of surveys completed by the number of surveys started by respondents) was 79.4%. Another limitation of this survey instrument was that it has not been previously validated and is 1210
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largely exploratory. More detailed background of the participants' experiences (i.e. the specific curricular requirements at their respective pharmacy programs) was not assessed. It is important to note that not all colleges offer an APPE in oncology nor can every student participate in one if desired due to rotation space limitations. Similarly, not every PGY-1 residency offers an elective oncology rotation. Finally, this survey only explores training as it relates to preparedness, exposure, and support for oncology practice; it does not explore other pharmacy specialties of interest to students (e.g., psychiatry, pediatrics) which may reveal differing results. For example, the ACCP Pediatrics PRN has published recommendations for PharmD curricula providing specific didactic hour recommendations, urging a required clinical rotation in pediatrics, and a changing attitude to acknowledge the ubiquity of pediatric pharmacy practice.23 Oncology pharmacy practice may benefit from similar guidance by stakeholders. The OES provides needed insight into the potential opportunities specific to oncology pharmacy education. One of the objectives of this study was to assess factors that predict pursuit of a PGY-2 oncology residency. The foundation of a PGY-2 specialty residency is the PharmD degree and a PGY-1 residency. The researchers did not directly ask the participants how their PGY1 residency impacted their pursuit of a PGY-2 oncology residency, which is a limitation of the study, but participants were asked how post-graduate training generally prepared them for their current position in oncology. Another limitation of this study is the limited exposure of student pharmacists to practicing oncology pharmacists within their didactic and experiential experiences, which could result in a limited ability of participants to provide information on how their PharmD program influenced their career in oncology. In a 2012 survey, Newton et al. found that 103 instructors taught oncology pharmacotherapy across 116 schools and colleges of pharmacy. Adjunct faculty or guest lecturers were used by 43% and about 15% of programs used faculty who did not practice in oncology.8 The 2016 Accreditation Council for Pharmacy Education Standards do not require student pharmacists to have an oncology APPE rotation (ACPE Standards) and most schools offer oncology as an elective rotation.18,24 In the survey by Newton et al., of 116 schools and colleges of pharmacy, most offered one or more oncology APPEs, but the researcher did not indicate what percentage of students actually completed such a rotation. Older schools and colleges of pharmacy (established longer than seven years) tended to provide more diversity in their APPE oncology rotation offerings.8 In a more recent 2015 survey of 62 schools of pharmacy, most schools (73%) offered fewer than 30 oncology APPE rotations and a median of 15% of students actually took an oncology APPE each year.9 Finally, a limitation to the survey included the potential for bias related to outside potential exposures to oncology. These exposures may have occurred before enrollment in a PharmD program or oncology APPE or residency. This limitation was mitigated by the ability of the respondent to provide information in the open-ended responses to share important events or experiences that may have ignited their interest in the field of oncology (i.e. cancer diagnosis in the family). Conclusion In this national survey of currently practicing US oncology pharmacists, several elements regarding practice preparedness, exposure, and support were elucidated. Namely, it was found that APPEs in oncology, as well as the degree to which didactic curriculum in oncology prepared the learner, were significant predictors of the pursuit of a PGY-2 in oncology pharmacy. A multitude of opportunities for development of PharmD curricula with respect to oncology are possible with these findings. While not every student pharmacist will pursue oncology, it is important to recognize that many, if not most, of those on the cusp of beginning their pharmacy careers will contribute to the care of the growing number of cancer survivors in the US. Thus, it is critical to elucidate strategies to ensure that not only are these students prepared, but also that they feel equipped to engage in their own endeavors of self-teaching and life-long learning, especially given the fast-changing nature of cancer care. Further studies could explore how specific aspects of the didactic curriculum impact the level of preparedness of the pharmacy student (e.g., through topics covered, case studies, or interprofessional opportunities.) Also, studies examining which elements allow a student pharmacist to feel prepared to independently seek further training in oncology are needed. Finally, additional research could examine the perceptions of RPDs of oncology programs regarding candidate preparedness. Disclosures The authors have no financial disclosures to report Declaration of competing interest The authors have no conflicts of interest to report. References 1. Hematology/Oncology (Cancer) Approvals & Safety Notifications. US Food and Drug Administration. https://www.fda.gov/drugs/resources-informationapproved-drugs/hematologyoncology-cancer-approvals-safety-notifications. Published 8 August 2019. Accessed 7 September 2019. 2. The state of cancer care in America, 2017. A report by the American Society of Clinical Oncology. J Oncol Pract. 2017;13(4):e353–e394. https://doi.org/10.1200/ JOP.2016.02074. 3. Miller KD, Siegel RL, Lin CC, et al. Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin. 2016;66(4):271–289. 4. Rooney JE, Ponushis A. A giant leap toward combating cancer. Academic Pharmacy Now. 2017;10(2):10–16. 5. Cavallo J. Who will care for patients with cancer? The confluence of looming oncology workforce shortages just as demand for cancer care explodes has experts searching for solutions. The ASCO Post. http://www.ascopost.com/issues/august-15-2014/who-will-care-for-patients-with-cancer/. Published 15 August 2014.
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