With the December 2023 publication of what they have dubbed the Patient Presentation Problem-Based Learning Curriculum (PPPC), faculty at the Hackensack Meridian School of Medicine, in Nutley, New Jersey, are aiming to revolutionize medical training and provide students with an innovative curriculum that takes the focus away from the textbook and integrates basic and clinical sciences to hone the decision-making skills they will need in their careers.

“We’re a new medical school—our first class matriculated in 2018—so we had the incredible opportunity to build a medical school from a blank slate in a mission-driven fashion,” said Miriam Hoffman, MD. “PPPC is a great example of how the vision and the mission informed the what as well as the how. One of our guiding principles was that everything our students learn should be grounded in the community and clinical context.”

Research by Hoffman and coauthors published in Medical Teacher explained that the PPPC is based on the Master Adaptive Learner model, which aims to develop students into self-regulated and lifelong learners who are equipped to practice medicine in a fast-paced environment. The paper laid out the 9 guiding principles of PPPC: A weekly clinical case serves as the scaffolding of the curriculum; the case should allow students to apply basic science to clinical medicine; structured and unstructured discussion time concerning the case should take place; the case should be presented with a discussion to practice clinical reasoning; at the end of the week the group gathers to review the knowledge gained during the week; formal and informal feedback on specific skills is provided; students will utilize outside resources to answer clinical questions; PPPC is primarily student-driven, allowing students to hone in on their individual needs; and the case should allow students to connect all determinants of health to patient care and outcomes.

, Hoffman, vice dean for academic affairs at Hackensack Meridian School of Medicine, outlined additional details of the novel curriculum, describing what separates PPPC from traditional medical teaching methods as well as the impact she hopes it will have on students during both their training and time as practicing physicians.

: How was PPPC developed, and what makes it unique among medical school curricula?

Hoffman: We have a guiding principle of everything you learn in the preclerkship curriculum is grounded in its clinical context. That’s very different from 2 years of lecture on basic sciences before you ever see your first patient. Our students are in the clinical setting; they’re [using] clinical skills from week 1 of this 16-month preclerkship curriculum. 

We have an entirely integrated curriculum; it’s not like [the students] have pharmacology on Monday, anatomy on Tuesday, public health on Wednesday, [etc]. Rather, they’re in 1 course that integrates all the content from the biomedical, behavioral, social, and health system sciences. That’s all integrated and framed in a clinical setting. With everything they’re learning, they’re tying it all together and doing cognitive integration. 

Many schools are struggling because they record their lectures, and they don’t require students to be in class. Students are not coming to class and they’re watching [the recordings] at home. I can teach that medical student [that they] need to learn about this receptor, because when sodium does this and chlorine does this, the gradient goes up, etc, [but] it’s abstract, it’s random, and it’s hard to learn. But if I’m teaching [them] about that very same receptor, and you’re mapping [it out in] a concept map, [then you realize] that’s why this 58-year-old has chest pain. Now I’ve grounded what you’ve learned in something relevant. You understand why you’re learning it, you understand how it connects to all the other stuff you’re learning, and you understand how to take what you’re learning and apply it to a patient case. 

[The PPPC] provides deeper, more meaningful, and long-lasting learning of that content than if I just put you in a lecture hall and lecture at you about this. You’re really using this information, applying it, and synthesizing it—that’s what we call higher-order cognitive goals, as opposed to just dumping it in your brain and dumping it out on a test. It’s more effortful and it takes more work. Students don’t always love it right away, but it gives them meaningful learning of the content, and they’re building those domain-general critical skills that they need to be lifelong learners and to be effective physicians.

What unmet needs for both students and faculty could PPPC fill, and what could its impact be on the landscape of medical education?

There has been a debate in the problem-based– learning literature of whether the focus [should] be more on the content or should it be more about the domain-general skills. What [PPPC] shows is a way to do that in an uber-integrated way. We’re completely integrating and achieving those 2 goals [through the PPPC]. That is a gap that this [curriculum] is demonstrating.

In terms of the [overall] landscape, our students have done amazingly well. Our goal is [to ensure] that you are a lifelong learner, that you can find information and apply it critically, but learning for that higher goal helps you do well on a standardized test [as well]. That’s why our students have knocked it out of the park on all 3 steps of the boards. Short-term recall doesn’t get you far. The goal is to get them to work smarter, which is effortful.

There’s evidence in the educational literature that with active learning students will [initially] say that they’re “not learning anything.” But when you look at medium- and long-term learning, they learn more from it, so there’s an inverse relationship there. You have to be OK with that because it takes a bit for students to learn how to engage in the process, and you have to support them in that. You have to really be explicit when you’re having students engage in this because it’s very different from how most of them spent their undergraduate college learning experiences.

What does the future hold for PPPC as far as improvements and potential expansion to other medical schools?

To execute this kind of curriculum, you really need to train your faculty. One of the things that’s critically important is that there’s collaboration between clinical faculty and basic science faculty in the building of the cases, in facilitating that Monday session, and so forth. We’ve invested a lot of time in developing all those faculty, and some of our greatest skeptics from the early years have become our greatest champions, and I appreciate them sticking with it.

Something we’re focusing on now and we’ll continue to focus on more is some of the overlap between what our students are doing in PPPC, what they’re doing with their small-group faculty, what they’re talking about with their advisers, and what they’re talking about with their clinical skills faculty, so that we’re really reinforcing it. It’s not like information mastery is only applicable in PPPC; it’s applicable everywhere else. The more that there’s an explicit integration, the more synergy [there will be]. 

We’re also continuing to build how we assess these skills because you can’t simply assess this with a multiple-choice test. We’re doing more assessment in our simulation center; we do a lot of simulation center training and assessment. [Also], at the end of every course, our students have what’s called an observed structured clinical exam, where they have standardized patients [played by actors] or simulators, which are very fancy manikins that have heart sounds, can speak, and have clinical findings. Additionally, 4 times throughout our curriculum we have a high stakes multi-station observed structured clinical exam. We simulate the clinical setting in a variety of ways. Continuing to build that and assessing more basic science content in the simulation center is an area of growth. 

Another area that we will be studying more is [further defining] what the outcomes are that we’re hoping to achieve. How are [the students] demonstrating them? How do we assess that? That’s a research question. 

We also just finished the first phase of a research project looking at what are called metacognitive moments, meaning moments when a student encounters [a] moment in a scenario where they don’t know what to do, where they’ve reached their limit. What do they do at that point? Do they think systematically, do they try to think about what additional information they need and how they should find it? How does emotion play into those cognitive processes? That’s an area that a group of us are actively looking at now as well.

SOM faculty publish study describing novel curriculum. News release. Hackensack Meridian School of Medicine. December 21, 2023. Accessed March 29, 2024. bit.ly/43LgYrp

Tripp T, Martinez O, Dreker M, Duffy C, Hoffman M. Expanding the scope of problem-based-learning at Hackensack Meridian School of Medicine; integrating domain-general skills with domain-specific content. 

. Published online December 17, 2023. doi:10.1080/0142159X.2023.2289850

Articles

Faculty at Hackensack Meridian School of Medicine developed a novel curriculum to improve medical training through practical, clinic-focused learning.

Innovation in the Classroom

During the whirlwind of emotions and newfound obligations brought on by a cancer diagnosis, the sexual health needs of patients are often overlooked by clinicians. Thus, this area of cancer care has often not received the proper amount of attention, and this lack of focused attention trickles down to the training of hematology and oncology fellows.

“After facing a cancer diagnosis and going through treatment, many patients are completely blindsided by the devastating impact to their sexual health,” Laila S. Agrawal, MD, a hematologist/ oncologist in the Department of Breast Medical Oncology at Norton Healthcare in Louisville, Kentucky, explained in a statement to 

. “As oncologists, it is our responsibility to counsel and prepare our patients for the adverse effects [AEs] of cancer treatment and address ways to help treat these AEs. Sadly, when it comes to sexuality, and especially so for women, there is often zero discussion about the impact of cancer treatment on sexual function. For the minority [of] women who do bring it up to their oncologists, many are made to feel as if there isn’t anything to be done about it, it is the price to pay for surviving cancer, or they should just be grateful to be alive. They may conclude that if their oncologist hasn’t brought it up, there is nothing that can be done to help. The truth is that sexual AEs are very common [and] can be very distressing, and there are multiple treatment options that can make things better.”

In a survey of hematology and oncology fellowship program directors, findings from which were presented during the 2023 American Society of Clinical Oncology Annual Meeting and subsequently published in 

, Jennifer Barsky Reese, PhD, FSBM, and coauthors sought to better characterize the current state of training of fellows regarding the sexual health of patients with cancer. Survey respondents (n = 114) indicated that less than half (49.1%) of programs offered some formal instruction on patient sexual health and only 36.8% offered formal instruction on safe sex practices, although 75.4% did so concerning patient fertility. Additionally, most program directors reported that a lack of experts was a significant barrier to instructing fellows of the topics of patient sexual health (74.3%), safe sex practices (67.9%), and fertility (53.5%; 

“It seems like reproductive health and fertility do tend to appear more often in clinical discussions with patients with cancer as opposed to sexual functioning,” Reese, an associate professor in the Cancer Prevention and Control Program at Fox Chase Cancer Center in Philadelphia, Pennsylvania, said in an interview with 

. “We know that these issues are not necessarily coming up as often as we’d like them to, even though they’re included in clinical guidelines for care. We’ve also known for many years [that the reason they are not properly integrated] is because of a lack of training in how to discuss these issues. I’ve tested provider interventions, [but] after discussing this issue with my colleagues, we thought, why don’t we start with the fellowship level? This is the moment in time in an oncologist’s training when they’re really steeped in learning about how to treat patients with various kinds of cancers and [should be] getting the whole experience of how to deal with all these issues.”

Reese and coauthors sent a survey to all hematology/oncology fellowship program directors in the US (n = 176); directors were identified via a search of the American Medical Association Residency and Fellowship Database website. The median number of fellows per program was 12 (range, 2-50).

The survey consisted of 14 items concerning fertility, sexual health, and safe sex practices. For each domain, program directors were asked about the coverage of topics via formal training, the use of informal training methods such as case studies or webinars, the barriers to providing instruction, and the amount of time dedicated to formal instruction relative to the overall academic year. The objectives of the study were to examine the provision of training in sexual and reproductive health topics during fellowship in terms of formal and informal instruction and to identify and interrogate the primary barriers to offering this instruction.

Additional findings from the survey revealed that most hematology/ oncology fellowship programs did not offer formal training in terms of the impact of cancer treatment on female sexual health (70.8%), male sexual health (71.7%), or body changes/ image (73.5%); a vast majority of programs also did not address patient distress related to sexual health/body image changes (75.2%) or dating and sexual relationships after cancer (85.8%). In terms of safe sex practices following cancer treatment, most programs did not cover the use of contraception/birth control (68.1%), sexually transmitted diseases/infections (85.8%), or safe sex practices during a patient’s treatment (69.0%).

In terms of barriers to providing formal training for oncology fellows around patient sexual health, program directors indicated that difficulty finding space in the curriculum and the lack of requirement or expectation that these issues were part of the program played a role. Specifically for sexual health, safe sex practices, and fertility, program directors cited difficulty in finding space in the curriculum as a significant barrier at rates of 49.6%, 54.0%, and 43.0%, respectively. A lack of requirement or expectation for patient sexual health, safe sex practices, and fertility to be included in a fellowship program was listed as a significant barrier at a rate of 56.6%, 60.2%, and 34.5%, respectively.

Outside of formal training, most program directors listed direct clinical experience as a training method regarding patient sexual health (78.1%), safe sex practices (72.8%), and fertility (77.2%). Case-based learning (38.6% vs 28.9% vs 42.1%, respectively), webinars or other online modules (21.9% vs 18.4% vs 16.7%), grand rounds (18.4% vs 12.3% vs 25.4%), and journal club (11.4% vs 7.0% vs 20.2%) were lesser-utilized additional training methods for fellows in the respective areas.

“If you’re training with an attending [clinician] who never brings up sexual issues with the patients, then that’s obviously going to limit what you’re learning,” Reese explained. “The problem with direct clinical experience being used as a primary method for training fellows in these areas is that practicing clinicians’ practice patterns are going to be very divergent from one to the next. Some may bring it up with every patient, some may bring it up with no patients, and some may bring it up at different times. It’s idiosyncratic, and we know that because most oncologists themselves “If you’re training with an attending [clinician] who never brings up sexual issues with the patients, then that’s obviously going to limit what you’re learning,” Reese explained. “The problem with direct clinical experience being used as a primary method for training fellows in these areas is that practicing clinicians’ practice patterns are going to be very divergent from one to the next. Some may bring it up with every patient, some may bring it up with no patients, and some may bring it up at different times. It’s idiosyncratic, and we know that because most oncologists themselves haven’t received training in these issues, the idea of learning from clinicians who themselves haven’t received training is potentially problematic.”

“If we could develop some kind of program or training that could be inserted within fellowship, it could potentially have a great impact on the field. These are future clinicians who are developing their practice patterns and their habits. We want them to go off into their own individual practice with the knowledge and skills to be able to address sexual issues and reproductive concerns,” she added.

To address the fellowship training shortcomings described in the survey, Reese and her colleagues are developing a National Cancer Institute– funded program to provide a series of skills-based training workshops aimed at providing oncology fellows with the tools to properly address the issue of patient sexual health. Ideally, she said, the fellowship programs themselves would bring in experts in this area to offer training to fellows, either in person or via virtual training sessions, and appoint a designated expert in this area within a given institution. Reese noted that many of the fellowship directors included in the survey wrote in and indicated that although patient sexual health training was not explicitly in their program, they recognized it as an important issue and would consider methods to emphasize it in the training of fellows in the future.

“Having formal instruction about management of sexual health concerns after cancer treatment, making opportunities for fellows to rotate through sexual health clinics, and providing access to more in-depth educational opportunities can help fellows be better prepared to meet this need,” Agrawal stated in conclusion. “Interested fellows can join professional societies like the International Society for the Study of Women’s Sexual Health, which hosts an in-person course and an annual meeting, and the Scientific Network on Female Sexual Health and Cancer, which has a scientific meeting as well as webinars. Fellows can become involved in these organizations to learn, find research mentors, and present research.”

Reese JB, Bauman JR, Sorice KA, Frederick N, Bober SL. Hematology and oncology fellow education about sexual and reproductive health: a survey of program directors in the United States. 

. Published online February 6, 2024. doi:10.1200/OP.23.00499

Sexual health needs of cancer patients are often neglected in clinical practice and training, particularly for women. A survey of hematology and oncology fellowship programs revealed inadequate formal training on sexual health, with barriers including lack of curriculum space and expert availability. Direct clinical experience is the primary training method, but its effectiveness is limited by variability in clinician practices. Efforts are underway to develop a National Cancer Institute-funded program to enhance training in this area, aiming to equip future oncologists with the skills to address sexual health issues effectively.

During the whirlwind of emotions and obligations brought on by a cancer diagnosis, the sexual health needs of patients are often overlooked by clinicians.

Identifying and Addressing the Overlooked Need of Patient Sexual Health

It is the season meetings. Thus, this editorial will focus on the importance of networking. Networking is an underutilized skill that requires practice but can have a high impact on shaping your career path.

During my time as a fellow, my mentor introduced me to individuals at professional meetings pertaining to my areas of interest. I did not realize it at the time, but this was the beginning of the development of my networking skills. Being from the South, I thought my mentor was just being collegial and friendly with his colleagues. In reality, this was a professional dance, and I needed to learn the steps in order to independently take to the dance floor. The ultimate goal of networking is to make connections that can lead to mentorship or sponsorship.

I am generally outgoing and gregarious. I am also an extroverted introvert. That means my bucket of energy is drained by the small talk with strangers that is part of networking. My energy is restored by quiet times, not by leaning into the discomfort of a meet and greet. This self-recognition is important because mindful management of the activation energy needed to network is critical to my successful networking.

Besides being someone who likes to recharge, I am also someone who likes to make my boss happy. Therefore, I have to view networking as part of my job, not only to promote my institution and its research but also to promote myself. National and international relationships can help build careers. Although social media networking is a growing reality, it lacks the element of personal relationship building and interpersonal skills that some potential mentors or sponsors require prior to endorsing someone for an opportunity.

I approach networking in the following ways:

I remember that networking is a part of my job and is not an indication of narcissism.

I actively dispel thoughts of self-doubt such as “They don’t really want to meet me” or “I don’t want to be a burden.”

I recognize that the individuals with whom I am networking have all been in my position before. They realize that this is part and parcel of life as a hematologist and oncologist. Thus, they expect to be networked with. I should not feel that my introduction is burdensome.

I recognize that although the initial approach is up to me, the outcome is out of my hands. The result of networking might be a new collaboration, a committee assignment, a new practice opportunity, or nothing at all. This is the equivalent of speed dating. Lack of concrete outcome does not mean failure, and it is not a personal insult.

I always come prepared. I bring business cards. I also take a quick look at the work of the person with whom I will be networking and ask genuine questions about their area of interest and their journey.

If pertinent, I will discuss information about myself or about my own work and professional goals, especially if that information aligns with their potential ability to sponsor or mentor.

Be fearless. At the next meeting, I challenge you to introduce yourself to 2 people each day, snap a selfie, make a new connection. It is part of your job and an important part of your professional journey.

Jill Gilbert, MD, is a professor of medicine and the director of the Hematology/Oncology Fellowship Program at Vanderbilt University Medical Center in Nashville, Tennessee. 

Networking is a crucial skill for career advancement, particularly in the medical field. It involves making connections that can lead to mentorship or sponsorship. Despite being energy-draining for introverts, networking should be viewed as a professional responsibility. Effective networking requires preparation, self-awareness, and the ability to overcome self-doubt. It is important to approach networking as a job requirement, not as an act of self-promotion. Building personal relationships through face-to-face interactions is more impactful than social media networking, and the outcome of networking efforts can vary widely.

Networking is an underutilized skill that requires practice but can have a high impact on shaping your career path.

Vol. 16 Issue 2 | Oncology Fellows

Innovation in the Classroom

Identifying and Addressing the Overlooked Need of Patient Sexual Health

Learning to Dance