Evaluation of a Remote Curriculum to Improve Internal Medicine Resident Knowledge and Confidence in Oncologic Emergency Identification and Management

Background

Oncologic emergencies (OEs) are life-threatening complications of malignancy that can present in multiple clinical settings and necessitate early recognition and intervention. Most medical resident training is experiential, but variability in exposure can yield gaps in medical knowledge that could result in delayed patient care. Remote curricula are commonly used to fill these gaps and reduce classroom burden on trainees. Given their time-sensitive nature, OEs are a prime target to augment clinical experience with a supplementary curriculum to prepare residents for new scenarios. This study evaluates whether an original, remote curriculum improves internal medicine resident knowledge of and confidence in recognition and management of OEs.

Methods

With expert faculty input, we developed a remote curriculum for first-year internal medicine residents at a tertiary care academic medical center. The curriculum includes 6 OEs: tumor lysis syndrome (TLS), hypercalcemia (hyperCa), neutropenic fever (NF), hyperviscosity syndrome and leukostasis (HVS/LS), superior vena cava (SVC) syndrome, and malignant spinal cord compression (CC). OEs were selected based upon prominence in the literature, morbidity and mortality, need for urgent management, and association with malignancy. We created an online lesson in Qualtrics for each OE. Each lesson was designed to be completed in 15 minutes via computer or smartphone. Lessons were delivered by email every 10 days, with reminders every 5 days. Learning objectives for each OE lesson were to 1) identify concerning signs and symptoms, 2) order appropriate workup, and 3) provide prompt management in the appropriate clinical setting. Lessons included clinical questions and evidence-based information delivery contextualized by case presentations.

We evaluated the curriculum’s efficacy with a randomized, controlled study. First-year residents were randomly assigned to two groups (“Intern A” and “Intern B”). We built assessments of knowledge and confidence with expert faculty input. Confidence in identifying and managing each OE was assessed by Likert scale (“1 - completely confident,” “5 - not at all confident”). Knowledge was evaluated with 3 multiple choice questions per OE, for a maximum knowledge score of 18. After both groups completed the pre-test, Intern A received the curriculum. After curriculum completion, both groups completed the post-test. All interns were required to complete the curriculum, but research participation was optional. Residents consented to participation prior to each test administration. All lessons and research activities were anonymous. Analysis was completed in GraphPad Prism 9 using the unpaired t-test or one-way ANOVA with post-hoc testing, as appropriate.

Results

Thirty-nine internal medicine residents completed the curriculum. Twenty were assigned to Intern A and 19 to Intern B. Intern A had 10 pre-test respondents (50.0%) with a mean knowledge score of 9.13 (50.7% correct), and Intern B had 13 pre-test respondents (68.4%) with a mean knowledge score of 9.35 (51.9% correct). There were no differences by OE-specific score. Baseline confidence was similar between groups (Table 1).

Comparison of mean knowledge scores is shown in Figure 1. Intern A and B had 9 (45.0%) and 10 (52.6%) post-test respondents, respectively. Both Intern A (mean 14.2; 95% CI, 12.8 to 15.7; 78.9% correct) and Intern B (mean 12.2; 95% CI, 10.5 to 13.9; 67.8% correct) significantly improved their knowledge scores compared to prior, though Intern A had a more marked effect size (Intern A mean difference 5.02; 95% CI, 2.84 to 7.21; P<0.0001; Intern B mean difference 2.66; 95% CI, 0.660 to 4.66; P=0.006). Intern A confidence significantly improved from the pre-test in both the identification and management of HVS/LS and SVC syndrome. Intern A confidence was significantly better than Intern B confidence in management of SVC syndrome at the time of the post-test (Table 1).

Conclusions

Baseline intern OE knowledge scores were sub-optimal. Intern participation in a remote OE curriculum improved knowledge acquisition to a greater degree than experiential learning alone. Confidence in identification and management of OEs with low pre-existing confidence, such as HVS/LS and SVC syndrome, improved in the remote curriculum. Further study should evaluate knowledge retention over time, resident clinical performance, and patient outcomes.