Designing, Implementing, and Evaluating of Teaching Scholarship in Virtual Multidisciplinary Tumor Board

doi:10.21203/rs.3.rs-2242899/v1

Background

Cancer management has become increasingly challenging due to the emergence of personalized approach which requires careful assessment, multidisciplinary efforts, and experienced physicians.

Because of the COVID-19 pandemic’s effect on executing all medical meetings as well as multidisciplinary tumor boards (MTB) we decided to design, perform and evaluate a teaching scholarship in virtual MTB for urologic cancer patients.

Methods

In this prospective study from December 2020 to July 2022, the authors evaluated designing, implementation, and learning efficacy of a virtual tumor board in the urology department of Shahid Beheshti University of Medical Sciences (SBMU). All the faculty members (N=25) and urology residents (N=35) were included in this investigation. To make the sessions, multidisciplinary, other related departments including pathology, radio-oncology, medical oncology, radiology, and nuclear medicine were also included. Virtual tumor boards were implanted monthly in twenty sessions.

Results

A short interview was conducted for the needs assessment. The faculty members and residents’ statements were divided of high, intermediate, and low importance. After implementation satisfaction questionnaire based on the first level of Kirkpatrick model was recorded and the means were 76% and 71% in faculty members and residents respectively for virtual execution. Results of evaluating the intervention according to the second level of Kirkpatrick model and through the tests before and after tumor boards were recorded and the mean differences evaluated by paired t-test were statistically significant. In the last step for external evaluation, the satisfaction rate of 5 arbitrators was 75% for executing a proper virtual MTB.

Conclusion

A virtual board is an effective learning method for medical education of urology residents. It could help practitioner to coordinate and discuss with different specialties and leads to the best decision for urologic cancer patients.

Cancer

E-learning

Medical education

Scholarship

Tumor Board

Cancer management has become an increasingly challenging due to emergence of personalized approach which requires careful assessment, multidisciplinary efforts, and experienced physicians. Considering this fact that there is increasing knowledge in cancer management and increasing trend of sub-specialization among specialties related to cancer treatment, tumor boards (TB) have become successfully accepted for better management and evidence-based decision-making (1). The purpose of TB is to provide a thorough evaluation of each cancer patient regarding pretreatment, treatment, and survivorship. This approach leads to proper staging, diagnosis, treatment modalities, management, follow-up and recurrence monitoring (2).

Multidisciplinary tumor boards (MDT) consists of a diverse specialties including medical oncologists, radiation oncologists, surgeons, radiologists, and pathologist cooperating to achieve high-quality treatment recommendations for cancer patients (3). Studies have reported that multidisciplinary approaches in tumor boards result to improved cancer patient’s treatment. However, there is required to introduce novel approaches that enable community providers to access tumor board sessions regardless of their geographical locations. While, some providers in urban hospitals have complete access to tumor board sessions cuss and review all types of cases, there are some hospitals located in rural areas lack access to tumor boards sessions (4). Furthermore, COVID-19 pandemic has altered the management and treatment approaches of patients especially cancer patients and multidisciplinary cancer management has become more challenging to manage. Therefore, there is need to create and form virtual multidisciplinary boards to improve collaboration between healthcare providers across various geographical locations and in different situation such as COVID-19 pandemic. Moreover, transition to virtual tumor board meetings gives providers this opportunity to reduce time wasted for travel and allocate proper cases and specialists (3).

Shahid Beheshti University of Medical Sciences (SBMU) is one of the biggest medical educational university in Iran with different hospitals serving urological cares across Iran’s capital, Tehran. In this regard, we performed a prospective study to examine efficacy and acceptability of virtual tumor boards for urologic cancers in educational hospitals of SBMU. In this study, we aimed to evaluate the efficacy of virtual tumor board meetings on the learning efficacy of urology residents and acceptance of virtual tumor boards among urology professors and residents.,

This was a prospective study, evaluating designing, implementation, and learning efficacy of a virtual urology tumor board in the Urology department of Shahid Beheshti University of Medical Sciences. This study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.SME.REC.1400.095).

Subjects and participants

Urology department of Shahid Beheshti University of Medical Sciences is not large in terms of the number of faculty members and residents. Therefore, inclusion and exclusion criteria were not determined and all the urology faculty members (N=25) and urology residents (N=35) were included in this investigation. To make the sessions multidisciplinary, the panelist were invited for each session from other related departments including pathology, radiation oncology, medical oncology, radiology, and nuclear medicine.

Setting

Virtual tumor boards were implanted monthly in twenty sessions. Shahid Beheshti University of Medical Sciences is the second medical and educational university in Tehran, Iran and one of the biggest national cancer referral center in Iran. It provides all cancer-related services such as radiotherapy, chemotherapy, and cancer surgery. Strong point that was considered for the designation of this study was the presence of different disciplines and specialties including urology, pathology, radio-oncology, medical oncology, radiology, and nuclear medicine departments. Tumor boards consists of three parts: (1) the first part is the introduction of cancer patient, (2) the second is the panel of specialists and experts who discuss the diagnostic and treatment modalities of the cases, (3) and the third part includes the learners which consists of the urology residents in our study. In virtual tumor board the fourth part is the online platform which the meeting has been hold in it, after discussion with experts in the field of information technology we decided to use Skyroom application.

Designing, implementation and learning framework

The aim of this study was to design, implement, and evaluate the efficacy of virtual tumor board on learning of urology residents. In order to identify and assess the requirement and needs of the study participants in all three parts of tumor board, a questionnaire was completed by the faculty members and urology residents before the organizing the program.

In order to evaluate the results of virtual tumor board sessions on participants, we recorded questioners according to Kirkpatrick model at the first and second level (5). Results of this learning program and the level of satisfaction of participants according to first level of Kirkpatrick model was recorded in three areas including: 1. achieving one clinical decision for the treatment and management of cancer patient, 2. evidence based topic, 3. and applicability of the content. Since the tumor board sessions were implanted virtually, virtual presentation was included as the fourth part in the questionnaire. For designing the questions of this part, in addition to opinions of faculty members and residents, the opinions of the experts in the field of information technology was also obtained. Evaluation the results of learning program on the learning of residents was done according to second level of Kirkpatrick model. This evaluation conducted before and after the implementation of the tumor boards in 5 consecutive sessions. In the beginning of each TB pre-test and post-test of the previous session were taken virtually. For the management of the meeting, two coordinators were assigned for each session to handle the meeting, manage the timetable, interact with participants, and cooperate with information technologist to eliminate probable technical issues.

Data collection and statistical analysis

This study took place over a 20 months’ period from December 2020 till July 2022. Data were recorded through short interview before implementation of the sessions to assess the needs of stakeholders and survey after the sessions to evaluate the effect of the program. Statistical analysis included descriptive analysis and paired t-test. All descriptive and statistical analysis were performed using Statistical Analysis System version 9.1 software. P value < 0.05 was considered statistically significant.

Urology department of Shahid Beheshti University of Medical Sciences consists of 25 faculty members (including assistant professors, associate professors, and full professors) with mean age of 52.2. The gender of faculty members included 4 females and 21 males. A short interview was conducted with all the faculty members regarding their needs for the holding of virtual tumor board. Their statements in a 5-point Likert scale were summarized into three groups of high, intermediate, and low importance. These items are presented in Table 1.

Table 1: Needs of faculty members regarding holding of tumor board sessions.

	Needs of faculty members	Importance
1	Discussing patients’ problem in an evidence-based manner	High
2	Discussing cases in a multidisciplinary manner	High
3	Reaching out one or more management and treatment method for cases	High
4	Definite and observed time table for each patients and sessions	Intermediate
5	Implementation of sessions with cooperation with other universities	Intermediate
6	Complete para-clinical explanation of cases including radiology and pathology images	Intermediate
7	Involvement of urology residents in the discussions to have educational tumor board sessions	Low
8	Coordination with scientific programs of other faculties and universities	Low
9	Avoiding lectures and presentations in a patient-oriented manner	Low

In the next step, we interviewed with urology residents and recorded their needs regarding the holding of tumor board sessions. It worth mentioning that residents in first and second year are more involved in emergency department and on the front line of visiting patients and they implement the medical orders of their senior residents. Therefore, most of their time is on duty, taking patients’ history, and matters related to hospitalization and discharge and have less opportunity to study and contribute in scientific meetings. On the other hand, third and fourth-year urology residents are more involved in surgeries and patients’ decision making, therefore, they have more time for studying and participating in scientific programs. Therefore, the needs of residents would be different according to their entry year and should be divided (Table 2).

Table 2: Needs of urology residents regarding holding of tumor board sessions.

	Third and fourth year urology residents	first and second year urology residents	Importance
1	Avoiding high specialized topics	Making it possible to participate in program	High
2	Limiting the number of patients in each sessions	Definite and observed time table for each patients and sessions	High
3	Educational explanation on each radiology images	-	High
4	More participation of residents to maintain sessions more educational	Having the opportunity to pre-study the topics	Intermediate
5	-	Participation of residents from different discipline	Intermediate
6	Provide follow-up of patients in the next sessions	-	Low
7	Definite and observed time table for each patients and sessions	-	Low

Satisfaction questionnaire based on the first level of Kirkpatrick model was recorded and is presented in Table 3.

Table 3: Satisfaction of faculty members and urology residents from tumor board sessions.

Satisfaction items	Faculty members	Urology residents
Achieving a specific clinical decision (number, percentage)	23, (92%)	30, (85%)
Evidence-based discussions (number, percentage)	21, (84%)	28, (80%)
Clinical applicability of topics (number, percentage)	24, (96%)	31, (88%)
Proper virtual presentation (number, percentage)	19, (76%)	25, (71%)

Results of the intervention was evaluated according to second level of Kirkpatrick model and through the tests before and after tumor board in 5 consecutive sessions. Table 4 shows the scores of tests.

Table 4: Mean score of 100-point pre-tests and post-tests of urology residents of Shahid Beheshti University of Medical Sciences.

	Third and fourth year residents		P-value	First and second year residents		P-value
Tests	Pre-tests	Post-tests		Pre-tests	Post-tests
1	43.2	61.4	<0.05	34.6	45.7	>0.05
2	59.6	83.9	<0.05	41.9	63.4	<0.05
3	74.3	95.7	<0.05	55.4	83.3	<0.05
4	78.2	97.6	>0.05	64.7	89.9	<0.05
5	83.5	98.8	>0.05	71.9	90.8	<0.05
Total	67.76	87.48	<0.05	57.48	74.62	<0.05

In the next step for external evaluation as the last step in Glassick's Criteria (6) for evaluating educational Scholarship, we invited 5 faculty members of urology department of Tehran and Iran University of Medical Sciences to participant and oversee the virtual tumor board sessions to explain their critics and suggestion about the implantation of the program. We also obtained their satisfaction rate regarding the implementation of virtual tumor board sessions and is shown in Table 5. Their comments were collected through a short interview and are presented in Table 6 according to their importance.

Table 5: Comments of faculty members of other medical universities.

Satisfaction items	percentage
Achieving a specific clinical decision	90%
Evidence-based discussions	88%
Clinical applicability of topics	96%
Proper virtual presentation and technical matters	75%

Table 6: Recommendation of external evaluators regarding the virtual tumor board sessions.

	Suggestions	Importance
1	Providing a balanced mix of rare and common diseases in sessions	High
2	Proper time management for each case	High
3	Improving the quality of radiology images	High
4	More participation of urology residents in sessions	Intermediate
5	participation of urologic oncology fellowship residents in sessions	Intermediate
6	Using more different specialties in sessions	Low
7	Provide follow-up of patients in the next sessions	Low

The primary goal of this study was to evaluate whether implementation virtual tumor boards in Shahid Beheshti University of Medical Sciences is attainable. We demonstrated that virtual tumor board is highly accepted and satisfactory by the faculty members and urology residents and is an effective learning method for the urology residents. Furthermore, we investigated the weak and strong points of our program which could be used in upcoming scientific programs. As shown in the result section, virtual tumor board sessions, which is one of the requirement of the surgical departments that have cancer patients, was highly satisfactory for the faculty members and urology residents. We also tried to organize the program according to needs and opinions of stakeholders. Unfortunately, one of the most important beneficiaries, the patients, were ignored in this research, we could not obtain their opinions regarding the amount of profit they got from holding these sessions.

Positive point of this investigation was need assessment in faculty members and urology residents, which, as expected, was different from each other’s. The most important concern in urology residents was the opportunity to participate in the meetings. Because due to large number of patients referred to urology department of Shahid Beheshti University of Medical Sciences, the most time of resident is spent on clinical and medical care rather than studying and participating in scientific meetings.

Regarding technical problems, most of the participants (76% of faculty members and 71% of urology residents) were satisfied and reported low technical issues. However, the most important technically occurred issue was the result of bandwidth down speed.

There are several studies supporting the utility of virtual tumor board in medical education of residents. A study conducted by Marshall et al. in 2014, tried to evaluate the satisfaction and acceptance rate of virtual tumor boards. They indicated that virtual tumor boards are highly feasible and acceptable and its effective was equivalent to that observed in personal tumor board sessions. Therefore, they concluded that implementation of virtual tumor board is a validated method for medical education (7). Another investigation conducted by Gagliardi et al. in 2003, assessed the efficacy of videoconferences for the oncology rounds and surgeons. The majority of participants (75%) were satisfied with the virtual session, demonstrating that it is possible for oncologists and surgeons to engage in a multidisciplinary virtual rounds (8). A recent study conducted by Davis et al., revealed that holding tumor board sessions virtually increased number of participant with different specialties (9). A study conducted by Hopkins et al. in 2022, showed that 72.5% of participants found that virtual tumor boards are more time efficient with same productivity as personal tumor boards, 85.5% found that virtual tumor boards are easier to participate, and 89.9% declared that decision-making process was not affected by this format (10).

In this study the authors showed this training scholarship program could overcome the training problem which was explained by Abedi et al in urology residency training program in Iran during COVID-19 pandemic (11) and this virtual tumor board is an effective method for improving learning in urology residents, as demonstrated by level 2 Kirkpatrick model in our study. Senior urology residents had greater mean score compared to junior residents which could be due to more time opportunities that senior residents have to study. Pre-test and post-test score improved gradually and over time, indicating that virtual tumor board is an effective learning method. Furthermore, post-test scores were always higher than pre-test scores but did not always showed a significant difference. These results could be due to the repetition of some common contents in sessions that helped residents to better remember such these topics.

For improving the learning objectives and efficacy of these sessions, we invited differed urology specialties and related specialties such as pathology, radiology, nuclear medicine, radio-oncology, and medical oncology. Holding tumor board virtually, making it possible to participate in the sessions from all part of the country and even in some cases from abroad. As an example, we invited Iranian urologist living in other countries such as USA, Canada, and England to share their opinions and management methods for each case and it helped to make sessions more interesting and improved scientific richness of the sessions. With slow progression of the COVID-19 pandemic, we decided to continue our sessions in a hybrid format, meaning that our sessions included both virtual and personal format and it helped us to hold the sessions more collaborative and available for dispersed colleagues.

Limitations

This study had some limitations. First, the quality of the radiology images was low and as one of the important priorities of the residents was get familiar with reading stereotypes of radiology, we tried to reduce the number of images on each page and increase the quality of each image. However, we were not able to completely remove this issue. We tried to use picture achieving and communication system (PACS) to provide images, however, this system was only available for the patients referred from the center. Second, creating and maintaining audience participation was the duty of session managers which was done appropriately in some circumstances. However, there were always some participations that did not interact and were not involved in sharing their opinions and commenting. A solution should be found to better manage and handle the sessions to give these people more opportunity to interact. Third, satisfaction of patients and their related needs did not consider in this study.

Virtual tumor board is an effective learning method for medical education of urology residents. It could help practitioner to coordinate and discuss with different specialties. This method increases convince for participants, reduces travel time to central location, and makes it possible for every provider to participate in sessions regardless of geographical distance.

Ethics approval and consent to participate

This study was approved by the ethics committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.SME.REC.1400.095). All participants signed informed and all methods were carried out in accordance with relevant guidelines and regulations which were approved by ethics committee.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors state that there was no conflict of interest.

Funding

None.

Authors' contributions

F.A. and Z. Kh. conceived of the original idea. F.A. investigated and ran the project. Z. Kh. verified the analytical methods and supervised the findings of this work. All authors discussed the results and contributed to the final manuscript. F.S. wrote the manuscript with support from F.A. and Z. Kh.

Acknowledgements

We should appreciate our executive team in Urology & Nephrology Research Center, Labbafinejhad Medical Center, Shahid Beheshti University of Medical Sciences.

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No competing interests reported.

Designing, Implementing, and Evaluating of Teaching Scholarship in Virtual Multidisciplinary Tumor Board

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Abstract

Introduction

Materials and Methods

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

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