Teaching in radiation oncology: now and 2025—results of a focus group with medical students

The modern physician image extends by far beyond mere knowledge and skill. A variety of personal and practical requirements complement the role and should therefore already be considered in the training of future physicians [1, 2].

One in two cancer patients will receive radiation therapy (RT) during the course of disease [3]. As a result, radiation oncology (RO) plays a major role in the steady improvement of care for cancer patients of all ages with a wide variety of tumors [4]. However, this relevance does not seem to be reflected in the current curricula of medical studies at faculties in Germany [5]. Furthermore, RO plays a subordinate role in the awareness of students and many prejudices and uncertainties persist regarding this specialty [6, 7]. This indicates the importance of a nationwide curriculum with operationalized learning objectives, developed according to high quality standards.

The universities determine the details of cross-sectional teaching in their study regulations [8]. The teaching should be topic-related, interdisciplinary, and oriented towards the subject matter. RO is part of cross-sectional subject 11 “imaging procedures, radiation therapy, radiation protection” (Querschnittsbereich 11: Bildgebende Verfahren, Strahlenbehandlung, Strahlenschutz, QB 11), which also includes radiology and nuclear medicine [5].

In 2017, the Health and Science Ministers of the federal and state governments passed a resolution to revise and modernize medical studies in Germany. The Masterplan Medical Education 2020 (Masterplan Medizinstudium 2020) focusses on practical relevance and the acquisition of social and communicative competencies in the formation of future physicians [9]. The explicit contents of the core curriculum are specified in the National Competence Based Learning Objectives Catalogue for Medicine 2.0 (Nationaler Kompetenzbasierter Lernzielkatalog Medizin 2.0, NKLM), which has been revised since 2015 in an ongoing process in cooperation between Medical Faculty Association of the Federal Republic of Germany (Medizinischer Fakultätentag der Bundesrepublik Deutschland, MFT) and the Society for Medical Education (Gesellschaft für Medizinische Ausbildung, GMA) [10]. The NKLM and Subject Catalog (Gegenstandskatalog, GK) of the Institute for Medical and Pharmaceutical Examination Questions (Institut für medizinische und pharmazeutische Prüfungsfragen, IMPP) complement each other (“constructive alignment”) [10]. The GK specifies contents for the written part of the second section of the medical examination in Germany. The updated edition 5.1, which will become relevant in the coming months, also defines medical roles and activities of graduates [11].

The restructuring of the curriculum necessitated a new version of the Licensing Regulations for Physicians (Ärztliche Approbationsordnung, ÄApprO), which is to be implemented at all German universities by 2025 [12]. The Masterplan Medical Education 2020 allows students to individually design areas of their studies according to their individual interests (up to 20%) [10]. Thereby, the implementation in detail is left to the faculties themselves. This provides an opportunity to involve all parties of the faculty in the renewal of teaching. In this regard, the German Society for Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) has announced recommendations on the content and scope of how RO should be represented in the new curriculum [5].

A medical studies curriculum is a pedagogical design that summarizes the educational focus of a subject with operationalized learning objectives. Tangible learning goals and competencies are formulated, and observable characteristics of future physicians are named. Kern et al. distinguish six phases in curriculum development [13]. In addition to the needs analysis of experts (step 2), the needs analysis of learners as a target group is an indispensable step while developing a curriculum [14]. Therefore, we see the necessity in both: to optimize teaching in RO and to integrate students’ needs in further development of medical curricula.

To the authors’ knowledge, this is the first prospective study to survey students’ experiences and requirements of medical education in RO in Germany. It analyzes whether the actual recommendations reflect the assessment of the students and—in addition—which modules could be meaningful and useful from the students’ perspectives.

This prospective single-institution analysis shows that the students have substantial, and mostly also methodologically realizable ideas of teaching–learning methods in RO. From the medical students’ point of view, RO is currently underrepresented in the curriculum. Students would like to see a clear concept for teaching QB 11 without redundancies. Especially in the acquisition of communicative competencies, RO should be integrated more profoundly in the future. Finally, the results of the needs assessment in the group of medical students in the subject of RO agree with the expert suggestions of ÄApprO, NKLM, and DEGRO.

The experiences of the target group provide valuable information, resulting in an optimal concept for the implementation of the ÄApprO for teaching in RO. Ranasinghe et al. have already shown how qualitative feedback from students highlights certain key areas that require special attention when creating the curriculum [20]. It also provides space for possible creative solutions as proposed and perceived by students. Up to now, teaching of RO in Germany has been heterogeneous in terms of methods and content [21]. According to ÄApprO, an intensification of the longitudinal structure is considered necessary by the focus group participants and DEGRO experts alike [5]. Despite the clear separation in QB 11, teaching must be coordinated. A common guideline and agreements among lecturers minimize redundancies and thus improve the learning experience for both lecturers and students. It is necessary to define exactly what knowledge is relevant for all students, those who later refer patients from other departments as well as for those interested in RO. The student participants agreed that a revision of the concept of QB 11 is necessary for efficient education in RO. The blurring of boundaries between the subjects of QB 11 caused discussion in the focus group. While some wished for closer cooperation, others rather demanded a clear demarcation. Usually, students do not acquire the necessary knowledge for the diagnosis and treatment of tumors in early stages of their studies. However, this is essential for effective teaching in RO which is why students can benefit from integration of RO into a longitudinal–interdisciplinary oncology subject. So far, such a subject has been established at only 41.7% of the faculties in Germany [5, 8, 21, 22]. RT basics should be taught at an early stage in subjects such as biology, physics, and anatomy [5]. Oertel et al. demonstrated the feasibility of introducing RO in the preclinical part of medical education within an “Anatomy and Imaging” course [23]. Zaorsky et al. have already shown that a separate mandatory rotation in RO could reduce knowledge gaps of physicians regarding the indication for radiotherapy or its toxicity [24].

DEGRO experts support, and partly already offer, e.g., mentoring and supervision of scientific work (doctoral programs) or opportunities to join a specific section during Final Medical Year (Praktisches Jahr) [5]. Innovative and attractive formats oriented towards the needs of students are necessary to promote their interests and strengthen them in their development. Students are mainly guided by personal interests, job opportunities, role models, structured training, and salary when choosing their future profession [25‐27]. Radiation oncologists accounted for less than 1% of 385,149 physicians in 2017; close to 300 physicians with the specialty designation are in retirement [28]. RO society needs to retain medical students by providing sufficient information and guidance. This should be used as an opportunity and goal to attract future physicians to RO at an early stage in their studies [26, 27, 29].

Curricular renewal is not only about factual knowledge in the education of future physicians, but also about competencies that should be acquired during studies [30]. The Canadian Medical Education Directives for Specialists (CanMEDS) published the concept of CanMEDS Roles in 1996 [31]. Each of these CanMEDS Roles is based on key competencies that must be applied in that role [31]. This concept, originally developed for specialist training, is found in the education of young doctors worldwide [32]. Winseman et al. showed personal and professional growth to be the most important factors affecting empathy in medical education [2]. The wish to be educated and to represent the future role of a communicator was highly present in the focus group. It remains to be discussed and further examined whether students in general are overburdened in this role or whether they see this competence undervalued specifically in RO.

In agreement with the results of our focus group survey, the MFT and GMA call for asynchronous teaching–learning formats that enable self-directed learning [33]. Nonetheless, the effectiveness and use of synchronous interactive methods that benefit from direct exchange and diversity continues to be referenced. The Council of Science and Humanities (Wissenschaftsrat) generally demands that students be given sufficient space to design their elective area individually [34]. This part will make up 25% of future curricula and can be designed by students depending on their interests (Fig. 1). The draft of ÄApprO aims to teach the competent use of digital technologies. MFT and GMA support the use of digital formats as a supplement to established face-to-face teaching [33]. This was also confirmed by the recently published study results of Vorwerk et al. in the field of RO [35]. Oertel et al. also demonstrated the successful digital transfer of a core curriculum in RO fastened by SARS-CoV‑2 pandemic [36]. A study at the Technical University of Munich showed how one-dimensional formats in teaching can be supplemented by the flipped classroom principle to achieve an increase in the internalization of content [37]. In contrast to classic lectures, students come to the classroom already prepared and learn how to acquire knowledge themselves [38]. They train to work as a team to solve complex problems [39]. A study in the Republic of Korea examined how this model could be implemented in RO teaching [40]. In a pilot project, students received instructional videos in preparation for a thematically linked discussion on the following day. In a final questionnaire survey, the students showed a high level of motivation and satisfaction. However, aforementioned model shows weaknesses because such methods rely on the cooperation and motivation of each student [37, 39]. Modern teaching instruments are partly already integrated as in the ZOOM software or available online as a freeware tool (e.g., Mentimeter) and are easy to use [41, 42]. Possibility of digital teaching formats, anchoring of NKLM as a core curriculum and linking of theoretical and clinical content within the framework of a Z-curriculum were evaluated positively by the students. The Z‑curriculum describes an interweaving of basic, clinical–theoretical and clinical–practical contents over the entire duration of the study program. The respective parts shift from the basics to clinical activity (Fig. 1). Overall, different teaching formats should be combined for varied and efficient teaching. At this point, the German Medical Association (Bundesärztekammer) and the German Association of University Medicine (Deutsche Hochschulmedizin) have expressed their concerns over the increase in number of compulsory hours required for implementation after final development and revision of Masterplan Medical Education 2020: It will definitely lead to an overload of medical studies [43‐45]. Rabatta et al. stated that this will not only lead to a higher burden on students, but also challenge personnel/staff and finances. In addition, a fully developed financing plan for the restructuring is still missing [33].

Of note, our prospective study has some limitations. The study team exclusively used a qualitative, descriptive study design and did not intend to investigate quantitative data. Nevertheless, in-depth insights into the students’ experiences and the named needs and strategies point towards important aspects. However, the study was concerned with improving teaching in RO, so it can be assumed that participants are particularly interested in RO or at least more interested than average in improving teaching on the federal level. In the context of compulsory university courses, less motivated and interested students are to be expected. A needs analysis in a larger group of students that is not specifically interested in RO could therefore be necessary in the future. Furthermore, participants showed a wide range regarding medical knowledge due to a high heterogeneity in semester number. Some participants have not yet attended any or only some of the courses in RO; specific questions regarding the evaluation of some courses could therefore not be answered by them. Nevertheless, their insights affixed valuable additions. Finally, all participants were students at the Medical Faculty of the University of Cologne, so that only limited conclusions can be drawn about teaching on a federal level.

This study was intended to be exploratory and to yield suggestions for further research, rather than for instructional practice. Nevertheless, this research supports the improvement of medical teaching in RO. Further prospective quantitative and qualitative studies that consider each location of (university) medicine are needed to evaluate students’ needs in RO teaching in Germany and to optimize the upcoming curriculum of new ÄApprO, underlined, and focused by Vision 2030 for radiotherapy & radiation oncology in Germany [46, 47].

The present work is intended to support the integration of RO into the compulsory teaching of medical students in Germany. Longitudinal training of students on the possibilities and importance of RO as one of the leading players of tumor therapy should be the goal of curriculum development. The results of the needs analysis for the subject of RT are consistent with ÄApprO, NKLM, and DEGRO experts. Moreover, they complement them and should be considered in curriculum development of Masterplan Medical Education 2020. The results contribute to high-quality and target-group-oriented medical training in the subject of RO, increased visibility, and thus early attachment of future physicians to RO in Germany.