Page 0065

CANCER MANAGEMENT

64 CANCER CONTROL 2014

are outside the university system and function in a similar

way to those that have long existed in more developed

countries would be necessary to put this approach onto a

formal footing. The primary focus would be "competencebased" i.e., education, training

and knowledge assessment

strongly focused on clinical care. Such institutions would

require government approval and independent accreditation,

but could be entirely separate from the government. Their

responsibility would be ensuring that health care providers

beyond the primary level are appropriately qualified, have

access to continuing education, adhere to the professional

standards set and are accountable for their actions. They

would not provide treatment, although they could well act as

conveners for committees and assume responsibility for

developing national referral guidelines, patient "care-paths"

and standardized treatment regimens. The limiting factor in

the establishment of such bodies is the small size of the

oncological community in countries with limited resources.

This might be overcome by creating international

organizations of this type, such as the recently inaugurated

Hematology and Oncology Society of Africa (HOSA).10

International organizations would have the added potential

to create standards of care and curricula for trainees, as well

as the provision of examiners across many African nations.

University training lasting one to three years can seriously

deplete the already insufficient number of health

professionals in countries where most or all post-graduate

training is conducted in universities and the contribution of

trainees to patient care is small. In addition, a limited number

of university places as well as specialist training programmes

exist at each university (Table 2), which may lead to

unbalanced capacity building. The extreme shortage of

oncologists in regions such as East Africa could be addressed

by very short periods of training for doctors, or even medical

assistants, in the diagnosis or management of a single type of

a common cancer. Clinical training and procedures, e.g.,

spinal taps and bone marrow exams would be done "at the

bedside." Trainees would be exposed to the cancers more

frequently in their own country and learn to practise in a

resource-limited environment rather than in the relatively

luxurious settings of foreign institutions, or the artificial

environment of the classroom neither of which prepare them

for the devastating realities of limited or absent resources.

In a non-university setting, training could be done in any

cancer centre or unit. Oncology sub-specialties, especially,

may be best taught in the course of supervised patient care in

cancer institutions. Alternative cancer specialist educational

pathways of this type would mean that more specialists could

be trained without a reduction in access to cancer care during

the training period. Training in a cancer centre would

encourage the simultaneous development of interdisciplinary teams, to ensure patient-focused care and relief

of workload pressure on the oncologist. Specialists would not

necessarily give up caring for patients with non-malignant

conditions, and surgeons, for example, might continue to see

other patients whilst undergoing training in surgical

procedures for cancer. Some task-shifting may be necessary

to enable physicians to focus on those aspects of care that

only they can undertake while nurses or medical assistants

with specialized training - again, of the "bedside" type -

would undertake the delivery of chemotherapy and perform

procedures e.g. spinal taps and even endoscopies normally

performed only by doctors. In the long run, the training and

employment of social workers disciplines involved with

rehabilitation and "trackers" who ascertain the status of

patients who have completed therapy should increase

efficiency as well as provide improved data on survival rates.

Certification

To ensure appropriate standards, a process for assessing

professional competence would need to be developed, ideally

involving external examiners and certification of those who

meet the requirements. The focus of university education

would rightfully become academic education and research.

Once certified, junior specialists (assistant or associate

oncologists?) could aspire to become "fully trained"

oncologists with a broader clinical knowledge base,

equipping them to undertake a leadership role in cancer

treatment. Associate oncologists practising outside the

specialist oncology centre could develop an interdisciplinary

oncology team across the tertiary-community interface.

Constant augmentation of knowledge could be assured by a

programme of continuing education (involving credits),

consisting primarily of inter-hospital clinico-pathological

case conferences or lectures/discussions on issues of care. If

accepted as an alternative to a post-graduate university

degree, all hospitals with a trained oncologist could be

involved in teaching, as well as service provision, thereby

overcoming some of the obstacles that currently exist.

Root problems in the development of higher

education

In East Africa, approximately 50% of the population is less

than 15 years of age. This has an impact on both the economy

and education, since productivity and government income in

the form of taxes are both low and the need for teachers at all

levels is high. In the last decade, improvements in the number

of children completing primary education (although still

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