Effects of blended learning training for oncology physicians to advise their patients about complementary and integrative therapies: results from the multicenter cluster-randomized KOKON-KTO trial

Many oncology physicians are confronted with the topic of complementary and integrative medicine (CIM) in their daily work. Many cancer patients already use CIM or ask their oncology physicians about CIM therapies [1‐3]. Good communication about CIM between oncology physicians and their cancer patients could help to reduce potential pharmacological interactions between CIM and cancer treatment [4]. Furthermore, good communication can lead to higher levels of trust in cancer treatment and compliance, as well as increased patient satisfaction, less stress, and greater well-being [5]. To overcome knowledge- and communication-based challenges, structured training in the use of CIM in oncology is urgently required by oncology physicians [6, 7].

Generally, communication skills training for health care professionals who work with cancer patients has been widely implemented in recent years. Many of these trainings lead to improved communication skills, and oncology physicians who participate in such trainings are less likely to provide facts alone without individualizing their responses to the patient’s emotions [8]. However, evidence is limited as to whether training oncology physicians is not only beneficial for oncology physicians themselves but also well-tailored to the counseling needs of patients [8]. A paper from a consensus meeting among European experts emphasizes that trainings should support oncology physicians in feeling confident in mastering difficult communicative tasks. Moreover, it was agreed that training should enable physicians to respectfully take their patient’s clinical and personal context into account. In terms of educational methods, interactive and experiential approaches such as feedback and role-play are recommended so that physicians can reflect on themselves, their learning progress, and their communication [9].

An interprofessional consensus procedure focusing on competencies that are of specific interest for trainings in integrative oncology found that such consultations are accompanied by unique challenges [10]. For instance, there are many potential complementary and integrative medicine options with highly variable evidence bases [11], and a CIM consultation thus requires not only fundamental knowledge of CIM therapies but also the ability to provide evidence-based, balanced, resource-oriented, up-to-date CIM information that assists patients in making decisions. Moreover, oncology physicians should be open-minded and take patients’ beliefs into account [10].

In addition to the competencies taught, it is important that the information about CIM that is necessary to inform a patient is tailored to the needs of the physicians and to the consultation situation. Oncology physicians prefer lectures, face-to-face workshops, and flexible online education that is accessible all the time [12]. In regard to the consultation situation, the experience of a previously conducted trial shows that CIM consultations cannot be easily integrated into everyday practice due to time constraints and should therefore be brief and adjusted to the needs of both parties in the interaction [13].

The KOKON-KTO study was part of the Competence Network Complementary Medicine in Oncology (KOKON), a collaborative research project in Germany that was funded in a second funding period by German Cancer Aid [14]. The KOKON-KTO study (KTO = Consultation Training for Oncology Physicians) aimed to evaluate whether training oncology physicians to advise their cancer patients on CIM, in addition to distributing an information leaflet about reputable websites, had different effects on outcomes at the patient, oncology physician, and physician–patient levels compared to only distributing the information leaflet. The evidence-based blended learning training is tailored to oncology physicians with little experience in CIM who advise cancer patients about CIM in only 20 min [15]. This paper focuses mostly on oncology physician-reported outcomes.

Oncology physicians in the KOKON-KTO training group reported significantly less perceived stress after all consultations compared to the control group who only provided the KOKON-KTO information leaflet to their cancer patients. Regarding the perceived consultation skill competency measured after each consultation, no significant differences were found; however, oncology physicians receiving KOKON-KTO training scored lower on all items (less overburden, tension, and discomfort with the consultation situation) than control physicians. Oncology physicians in the intervention group were more confident in conversations and less likely to avoid CIM conversations. According to the qualitative data, the oncology physicians felt competent and well prepared for a conversation on CIM and for only providing the information leaflet, even though the latter felt somewhat impersonal.

The self-reported quantitative data of the patients in our study that have been published elsewhere support these findings. Patients who received the KOKON-KTO consultation exhibited higher levels of satisfaction in the group [20]. Both outcome levels (patient and physician) showed concordant trends between the groups, which result in a convincing basis for the KOKON-KTO training.

In a previous pilot study by Bloedt et al. [13], oncology physicians who were trained in a complementary communication blended learning program in providing advice during CIM-designated consultations achieved high patient satisfaction. However, the control group experienced comparable results, which might be explained by ceiling effects that are a common challenge in measuring the effects of communication trainings in cancer care [23, 24]. However, in this study, the view of oncology physicians who reported that additional consultations about CIM were difficult to integrate into everyday practice was also taken into account [13]. In our recent study, there was no difference in the subjective ability of the approach to be implemented between groups; therefore, 20 min appears not to interfere with everyday work.

In a study by Hayward et al., a complementary medicine practice guideline also led to positive results for health care providers, including oncologists (improvement in self-reported CIM knowledge and readiness to answer cancer patients’ questions about CIM) [25]. This education session was also created to accommodate the schedules of health care professionals and was available in multiple formats (in person as well as online). Shorter educational programs can serve as a sufficient alternative when oncology physicians aim to improve their CIM knowledge.

The oncology physicians in the control group in our study also received a short intervention and were introduced to providing an information leaflet about reputable websites on CIM. The majority of patients used the recommended websites, and the qualitative results showed that the oncology physicians found it helpful to use these resources. Sharing information leaflets might be a suitable alternative that is easy to implement in everyday care for oncology physicians who want to give their patients a helpful introduction to CIM, but also want to have more time for direct conversations on other topics [26]. The internet is a source that is frequently used to obtain information by cancer patients, but a study found that only approximately 1/3 of the obtained information influenced patients’ treatment decisions [27]. One reason for this discrepancy may be that online information is not evaluated in terms of quality and patients do not trust the information provided. Consequently, a pre-selection of high-quality, evidence-based, online resources about CIM and CIM-related adverse effects by health care providers might be helpful for cancer patients [28]. However, in addition to online information, oncology physicians should have knowledge and skills to inform themselves about specific information, such as the side effects of therapies, which could cause fear [29].

In our study, we used a blended learning method to train physicians. A review showed that it remains uncertain whether e‐learning alone improves or reduces health professionals’ skills [30]. A blended learning approach combines the advantages of online knowledge transfer, which can be adapted in its pace to physicians’ work lives with the possibility of direct interactions, exchanges, and relations with other learners, and the physical presence of the teacher during the onsite workshop.

In our study, we also measured how attitudes about the effectiveness and safety of CIM therapies changed after completing the e-learning. Oncology physicians displayed changes in the rated effectiveness and safety of most CIM therapies after participating e-learning. However, CIM therapies were rated as being effective and safe by most oncology physicians prior to the e-learning. Nutrition, physical activity, yoga, and acupuncture are the therapies that were mostly rated as effective and safe after e-learning. Patients’ expectations of CIM play a role in the treatment outcome [31]. However, to our knowledge, no studies have assessed how attitudes toward the effectiveness and safety of CIM therapies shape the recommendations of oncology physicians. Studying these associations between expectancies and attitudes toward CIM among physicians, and recommending those to patients, could help reduce bias and improve the quality of medical decision-making. For this, future research based on validated instruments as established for patient populations [32] is needed.

To our knowledge, this is the first study using a standardized framework [16], which was evaluated in a cluster-randomized trial of oncology physicians, interactions between oncology physicians and patients, and at the patient level [20]. The use of multiple assessment methods combining quantitative and qualitative measures provides a more complete evaluation of the training. However, our study has several limitations that need to be acknowledged.

Our study needs to be considered exploratory, and we did not measure effects on a single primary outcome. We involved a structured consensus approach for finding suitable outcomes for measuring effects [17], which led to the recommendation to measure several outcomes on three levels. The instruments for measuring our main outcomes were self-developed, as both need to be tailored to the specific study situation. Therefore, we do not have comparable data and no further information on the validity of the instruments. There might be over- or underestimations in specific groups due to self-reported data. We cannot rule out that oncology physicians rated their performance/the conversations more positively based on their perception in the situation. We were not able to completely blind the participants since they received a full intervention; however, the control physicians also received a short e-learning and material for their conversations (KOKON-KTO information leaflet). In addition, we used short-term (information about each consultation) and long-term (impressions after all conversations) information, which are both subject to bias. Long-term information can lead to recall bias, and oncology physicians might remember the most recent conversations more precisely. However, short-term information can be influenced by subjective emotions and might be of limited predictive value for long-term behavior. Furthermore, not all oncology physicians were able to conduct ten consultations with cancer patients, which results in limited comparability. In addition, we were not able to fully assess the implementation of the KOKON-KTO manual outside of the training situation. In our preplanned statistical analysis, we did not use the cluster as a random effect, as commonly done in cluster-randomized trials. As mentioned in our protocol publication [15]: the multilevel structure of the data is due to patients treated within a physician, and physicians working within a cluster. Because of the small number of physicians per cluster (either one or two) and the assumption that the communication varies more between single physicians than between centers, the center as cluster was not considered in the model. The results of the additional analysis, which adjusts for the specific center of the physician instead of just for the physician, did not differ in any clinically relevant way, indicating an overall robustness of the study results with respect to single physician versus center adjustment.

We did not video record the consultations based on experiences from a previous study [13]. Since the KOKON-KTO training follows a blended learning approach focusing not only on education on CIM-related knowledge but also on communication skills for oncology physicians, we cannot distinguish between components. However, we assume that both components are essential for effective communication with patients and cannot stand alone in training [5]. Moreover, even though randomization of oncology physicians took place, there were differences in the patient sample that oncology physicians selected for the conversations between the intervention and control groups. In the intervention group, there was a higher number of patients with more severe cancers, and the treatment was more frequently palliative in the control group than in the intervention group. This probably led to unequal preconditions for the conversations and may also influence stress during the conversation and one’s feeling of competence.

This exploratory study evaluated a novel education intervention for training oncology physicians in providing CIM advice in routine care. Providing structured CIM consultations following a blended learning training had positive effects on the perceived stress of oncology physicians but no significant effects on skill competency. Receiving blended learning was associated with higher confidence in CIM conversations and lower avoidance of CIM conversations. Oncology physicians felt well prepared for both measures—a full conversation about CIM and a simple provision of the information leaflet—even though only providing the information leaflet about recommended websites felt impersonal. The recommended websites were used by most of the patients. Therefore, providing information about recommended CIM websites could be a suitable and easy approach for oncology physicians. However, having information about the evidence base of the use of CIM therapies in cancer care, and how to communicate about CIM, can be an option to not only meet the needs of patients asking about CIM but also reduce stress for physicians.