Jennifer C. Kesselheim

Do pediatric hematology/oncology (PHO) fellows receive communication training?

The Accreditation Council for Graduate Medical Education (ACGME) has established communication as a core competency for physicians in training. However, data suggest that most pediatric residents perceive inadequate training in the delivery of bad news and the majority of former trainees in pediatric oncology received no formal training in the delivery of bad news during fellowship. The study examines communication training in ACGME accredited US pediatric hematology‐oncology (PHO) fellowship programs.

Communication Skills Training in Pediatric Oncology: Moving Beyond Role Modeling.

Communication is central to pediatric oncology care. Pediatric oncologists disclose life‐threatening diagnoses, explain complicated treatment options, and endeavor to give honest prognoses, to maintain hope, to describe treatment complications, and to support families in difficult circumstances ranging from loss of function and fertility to treatment‐related or disease‐related death. However, parents, patients, and providers report substantial communication deficits. Poor communication outcomes may stem, in part, from insufficient communication skills training, overreliance on role modeling, and failure to utilize best practices. This review summarizes evidence for existing methods to enhance communication skills and calls for revitalizing communication skills training within pediatric oncology.

Service: An Essential Component of Graduate Medical Education

Although service is fundamental to a physicians role, it is being harmfully undermined within the medical profession and in graduate medical education, according to surveys of residents conducted by the Accreditation Council for Graduate Medical Education.

Balancing education and service in graduate medical education: data from pediatric trainees and program directors.

Purpose To measure pediatric program directors’ (PDs’) and trainees’ perceptions of and expectations for the balance of service and education in their training programs. Method In fall 2011, an electronic survey was sent to PDs and trainees at Boston Children’s Hospital. Respondents described perceptions and expectations for service and education and rated the education and service inherent to 12 vignettes. Wilcoxon rank sum tests measured the agreement between PD and trainee perceptions and ratings of service and education assigned to each vignette. Results Responses were received from 28/39 PDs (78%) and 223/430 trainees (52%). Seventy-five (34%) trainees responded that their education had been compromised by excessive service obligations; only 1 (4%) PD agreed (P < .0001). Although 132 (59%) trainees reported that service obligations usually/sometimes predominated over clinical education, only 3 (11%) PDs agreed (P < .0001). One hundred trainees (45%) thought rotations never/rarely/sometimes provided a balance between education and clinical demands compared with 2 PDs (7%) (P < .0001). Both groups agreed that service can, without formal teaching, be considered educational. Trainees scored 6 vignettes as having greater educational value (P ⩽ .01) and 10 as having lower service content (P ⩽ .04) than PDs did. Conclusions Trainees and medical educators hold mismatched impressions of their training programs’ balance of service and education. Trainees are more likely to report an overabundance of service. These data may impact the interpretation of Accreditation Council for Graduate Medical Education survey results and should be incorporated into dialogue about future curricular design initiatives.

Discontinuing bevacizumab in patients with glioblastoma: an ethical analysis.

Glioblastoma (GBM) is a highly lethal malignant brain tumor that expresses proangiogenic factors, including vascular endothelial growth factor (VEGF). Bevacizumab (Avastin®; Genentech, Inc., South San Francisco, CA), a monoclonal antibody against VEGF, is routinely used in the U.S. to treat GBM patients whose tumors have progressed following initial therapy. The Ethics Advisory Committee at the Dana-Farber Cancer Institute was asked to provide consultation on two cases involving patients with recurrent GBM who were receiving bevacizumab. Despite evidence of disease progression, family members advocated for the continued use of bevacizumab because of its mild toxicity profile and concern that discontinuation would impair quality of life. However, continuing bevacizumab in this setting posed physical and financial risks to the patients and raised ethical concerns about resource allocation and justice. We analyze the ethical questions regarding bevacizumab discontinuation in the setting of progressive GBM. We articulate the potential benefits and harms of continuing the drug and identify guiding principles for drug discontinuation that should be made transparent to patients and families. With the increasing availability of new, modestly toxic, expensive drugs for patients with advanced cancer, questions of when to stop these drugs will become increasingly relevant.

Is Blood Thicker Than Water?: Ethics of Hematopoietic Stem Cell Donation by Biological Siblings of Adopted Children

M INOR SIBLINGS routinely donate hematopoietic stem cells (HSC) for transplantation. However, the ethical justification for using minors as donors is controversial. Prompted by a recent case involving a biological sibling who, because of adoption, had no intimate relationship to the potential transplant recipient, we review systematically the ethical foundation for using minors as HSC donors. Analysis of the various potential justifications for using minor siblings as donors suggests that HSC donation in this case is ethically impermissible. Looking beyond this particular example, we contend that optimal patient advocacy requires that generalist and specialist pediatricians be familiar with the ethical framework that guides decisions about accepting minors as HSC donors. A previously healthy 6-year-old boy who had been adopted as an infant was found to have acute lymphoblastic leukemia. Because initial cytogenetics revealed monosomy 7, allogeneic HSC transplantation was considered at first remission. The patient’s adoptive parents had maintained contact with his biological mother. Arrangements were made for his 3 younger biological siblings to be HLA typed as potential donors. Because none of the biological siblings was an HLA match, the patient completed chemotherapy for leukemia. He experienced a bone marrow relapse 36 months after diagnosis (1 year after therapy). He then received reinduction chemotherapy in preparation for unrelated donor transplantation. Informed and autonomous consent justifies allowing adults to serve as hematopoietic stem cell donors for related or unrelated recipients. When is it acceptable on the basis of parental permission rather than autonomous consent to allow a minor to donate HSCs? Is it permissible to use a biological sibling of an adopted child as a donor when no ongoing psychosocial relationship exists between the two? This question will become increasingly common as indications for HSC transplantation and the percentage of open adoptions increases. Although pediatric hematologistoncologists will be asked these questions most directly, primary care pediatricians should also understand the underlying ethical principles to advocate effectively for their patients who may be considered HSC donors or recipients. Furthermore, articulating a framework that clarifies the ethical issues in this situation may assist pediatricians in making a decision about the ethical appropriateness of HSC donation by minors in other unusual cases.

Social media in cancer care: highlights, challenges & opportunities

10.2217/fon-2016-0065

Humanism and professionalism education for pediatric hematology‐oncology fellows: A model for pediatric subspecialty training

Humanism and professionalism are virtues intrinsic to the practice of medicine, for which we lack a standard, evidence‐based approach for teaching and evaluation. Pediatric hematology‐oncology (PHO) fellowship training brings new and significant stressors, making it an attractive setting for innovation in humanism and professionalism training.

Risks and benefits of Twitter use by hematologists/oncologists in the era of digital medicine

Twitter use by physicians, including those in the hematology-oncology field, is increasing. This microblogging platform provides a means to communicate and collaborate on a global scale. For the oncology professional, an active Twitter presence provides opportunities for continuing medical education, patient engagement and education, personal branding, and reputation management. However, because Twitter is an open, public forum, potential risks such as patient privacy violations, personal information disclosures, professionalism lapses, and time management need to be considered and managed. The authors have summarized the benefits and risks of Twitter use by the hematology-oncology physician. In addition, strategies to maximize benefit and minimize risk are discussed, and resources for additional learning are provided.

Ethics and professionalism education during neonatal–perinatal fellowship training in the United States

Objective:The objectives of this study were to determine the perceived adequacy of ethics and professionalism education for neonatal–perinatal fellows in the United States, and to measure confidence of fellows and recent graduates when navigating ethical issues.Study Design:Neonatal–Perinatal Fellowship Directors, fellows and recent graduates were surveyed regarding the quality and type of such education during training, and perceived confidence of fellows/graduates in confronting ethical dilemmas.Result:Forty-six of 97 Directors (47%) and 82 of 444 fellows/graduates (18%) completed the surveys. Over 97% of respondents agreed that ethics training is ‘important/very important’. Only 63% of Directors and 37% of fellows/graduates rated ethics education as ‘excellent/very good’ (P=0.004). While 96% of Directors reported teaching of ethics, only 70% of fellows/graduates reported such teaching (P<0.001). Teaching methods and their perceived effectiveness varied widely.Conclusion:Training in ethics and professionalism for fellows is important, yet currently insufficient; a more standardized curriculum may be beneficial to ensure that trainees achieve competency.