Introduction

The two primary psychosocial dimensions of cancer are (a) the response of patients, families, and staff to the disease and its treatment and (b) the psychological, social, and behavioral factors that influence tumor progression and survival [1]. While the latter is probably the domain of oncologists and specialized practitioners of psycho-oncology, familiarity with the former is essential for health care professionals in any discipline since cancer patients face an enormous psychological burden [2].

Psychosocial concerns can impact on the expression of physical symptoms, function, emotional well-being, quality of life, and the capacity of patients to cope with their disease and its treatment [2, 3]. Basic psychosocial support followed by referral to specialized providers when appropriate is the responsibility of every health care provider [2]. Unfortunately, this process is often inadequately taught at an undergraduate level, further compounded by a lack of practical inter-professional education (IPE) and few opportunities to practice core communication skills in a team setting [2, 3].

Good communication is the cornerstone of optimal psychosocial support and includes expressions of sympathy, use of open questions, active listening, repeating and summarizing, actively encouraging questions, and providing written information [2]. Once health professional students are introduced to these skills, they are in a better position to make appropriate enquiries and respond sensitively to patients’ needs [2].

Oncologic therapies are often delivered by multidisciplinary teams (MDTs) who additionally have a duty to address patients’ psychosocial needs [2]. Optimal physical and psychological outcomes depend in part on how well the team collaborates, the degree of patient-centered care provided, the effectiveness of inter-professional communication, and the familiarization of team members with the roles and responsibilities of others [2, 3]. A well-integrated team also ensures that members and students rotating in this complex and emotionally stressful field are adequately supported [2].

The Cross Cancer Institute (CCI) Multidisciplinary Summer Studentship in Palliative and Supportive Care in Oncology is an elective, inter-professional 6-week summer placement designed to expose participants to the main psycho-oncology challenges facing patients and their families following a diagnosis of cancer, through treatment, recovery, recurrence, palliation, and end-of-life. The Studentship includes experiences in new patient clinics, follow-up during and after treatment, home visits, the inpatient setting and hospice, as well as an introduction to most oncologic therapies and tumor sites.

After an initial orientation, students’ schedules include mandatory clinical time, in which the full spectrum of disciplines involved in caring for cancer patients is introduced, and flexible clinical time, based on students’ interests. Preceptor-facilitated “fireside chats” are an opportunity to reflect on weekly experiences, inter-professional roles, and collaborative practice. An exploratory investigation or research project is required, as well as a 40-min presentation. In this paper, we describe the inaugural Studentship from the point of view of the first two participants and the supervising faculty member.

Background—clinical nutrition student’s perspective

Prior to the Studentship, I had not had any formal didactic IPE. Any interaction between professions was incidental. Classes within my own discipline used group projects to prepare us for working within a team. During these, one of the biggest challenges was assessing the personalities of other members; working in teams forces you to anticipate the perspectives of others in order to reach patient, personal, and team goals.

During my clinical placements, I was struck by the realities of a team-based approach, which seems to have one intention and many realities. My previous experiences as a student inter-professional team member ranged from minimal interaction with others to a fully collaborative model where I was highly involved in team dialogue and care. Working as a MDT should involve professionals coming together to provide complete care as no one person employs all necessary skills to address all physical and psychological patient needs. Well-coordinated care should be delivered without overlap and without gaps. Collaboration requires professionals to be secure in their own scope of practice, to share their knowledge with other MDT members as well as patients, and to be aware of the necessity of their involvement.

Background—medical student’s perspective

Prior to applying for the Studentship, I completed a Bachelor of Science, 1 year in an After-Degree Nursing program, and 2 pre-clinical years in medical school. I was first introduced to the idea of multidisciplinary health care during a summer job in which I worked with physicians, nurses, psychologists, and recreational therapists providing care for Alzheimer’s patients. This piqued my curiosity and motivated me more recently to join a student-run MDT providing holistic care to inner-city youth. I also completed a didactic IPE course in which students from ten health care disciplines are placed in teams to learn about other professions and develop small-group skills. Previous MDT experiences led me to believe that this approach was the best way to provide comprehensive care within a health care system plagued by staff shortages.

Background—supervising oncologist’s perspective

As a medical student, I participated in a 6-week summer program whose objective was to provide an “enriching experience in the provision of supportive care to patients with cancer” [4]. Participation in multiple types of experiences was encouraged without a specific focus on either multidisciplinary practice or IPE. That experience framed my view of the profound impact of cancer. I recall even now faces of patients who taught me so much in the midst of their suffering. I learned from physician mentors who were sensitive and compassionate, even when they could offer little of therapeutic benefit.

Over the past 5 years, my interest in MDT practice and IPE has been reinforced by the realities of care delivery in Oncology in Canada. As a team member of the Rapid Access Palliative Radiotherapy (RAPRP) [5, 6], I believe in the benefits that patients derive from a caring, holistic approach, especially given that many have psychosocial needs beyond my individual capacity to completely address. The Studentship took shape through a desire to pass on what I have learned from my RAPRP teammates, from undergraduates and residents, and above all from my patients.

Expectations and goals—clinical nutrition student’s perspective

I was looking forward to interacting with physicians, nurses, and other disciplines during the Studentship in a meaningful way but was unsure how I would be perceived. I wondered if my limited cancer-related knowledge might be a challenge. I was eager to understand more about the patient’s experience as well as that of a health care professional supporting a patient through treatment. Are there common emotions and experiences? I expected to be able to more fully understand the complexity of the disease and of how patients coped with the diagnosis. I also wanted to better understand how a patient prepares for life once cure is no longer an option. I expected to see the patient through a different lens and improve my awareness of their experience. Finally, I wanted to understand the role of medicine when the intent is not to cure.

Expectations and goals—medical student’s perspective

My primary goal was to develop communication and clinical skills. I could not have dreamed of a better way to work toward this goal than this Studentship. I was excited for the opportunity to work closely with physicians and other disciplines. I believed that I would discover what is necessary for a successful MDT by observing the delivery of holistic care to a high-needs population. I believed this experience would provide insight into how to appropriately interact with and support other health professionals and efficiently utilize resources. I hoped to incorporate these lessons into my future practice and share them with my peers.

Expectations and goals—supervising oncologist’s perspective

I expected the students to be exposed to the roles of other disciplines, to real-world MDT practice, and to the practice of Palliative and Supportive Care. The main goal was to focus on seeing the cancer journey and its challenges through the patient’s eyes. Our students were treated essentially the same as a patient who walks through our Institute’s front door without knowing what to expect. They attended a new patient orientation, initial consultations on treatment options, a chemotherapy teaching class, and cognitive therapy support groups, as examples (Fig. 1).

Fig. 1
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Example schedule (portion)

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Reflections—clinical nutrition student’s perspective

By the time the Studentship began, I had completed my mandatory clinical rotations and felt that I had a good understanding of my role as a dietitian. Some of the Studentship experiences helped to cement prior knowledge and MDT process. I witnessed teams of professionals who communicated strongly and in a timely manner, allowing each person to build on others’ assessments. The result was often a multidimensional, patient-centered care plan which addressed both emotional and physical well-being. On one occasion, I sat with the patient for the duration of their clinic visit as various professionals performed their interventions; the next week, I followed the MDT members. The care provided during the clinic provided significant relief beyond the treatment outcomes, however—relief that all of the patient’s concerns were being attended to through coordinated care.

There were also several experiences that I could have not anticipated. I was fortunate to observe a cognitive-behavioral therapy group which actually reframed my perception of the burden of cancer. It was eye-opening to hear patients discuss their concerns: feeling not like a person, but a tumor type; not knowing who they were speaking with or even who they could consider “their” doctor after meeting so many. This insight was enhanced by time spent with the Patient Concerns Officer. It is evident now that someone’s perception of their care is due in large part to the personal interaction between the individual and their providers. While I may have understood this on an intellectual level, it is another matter to listen to someone’s perspective firsthand.

What resonated most was the opportunity to witness interactions between physicians and patients. Dietitians are usually consulted after the diagnosis has been delivered and treatment options have been discussed. Observing a physician actually giving a patient their diagnosis had a profound impact on me as well as the patient. I was struck by how brave the patients seemed and how collected the physicians were. I felt that I would be quite ill-equipped to perform this. Some of the richest dialogue that we students shared with our preceptors was related to the emotional aspect of working in Oncology. Before this summer, I felt that emotion was an inappropriate response.

The strongest teams demonstrated to me that one’s traditional professional role can be secondary, just a foundation for one’s actual role, which can overlap with others’. Within a MDT, I learned that your role transforms into what is required for optimal functioning of the team. This is the ultimate expression of a team-based approach: where each professional is on a level playing field and the expertise of each enhances the team’s overall function. With a highly integrated team, each professional knows which other member can optimally meet a patient’s specific needs.

Being placed with a student of another discipline for 6 weeks was highly rewarding. My training being nearly complete, I had certain feelings about the medical profession. The Studentship became a valuable opportunity to reconstruct my perceptions. The dialogue between us as students was honest and enlightening. We challenged each other to examine additional points of view, and I was fascinated by how different our perceptions of the same situations could be! Working with a medical student led to a stronger appreciation of the role of the physician as the one ultimately responsible for patient outcomes. Where previously I have encountered physicians consulting with other providers before returning to their professional silo, I have now witnessed multiple physicians relying on others to enhance care delivery.

Reflections—medical student’s perspective

Each day of the Studentship was completely different. One morning I would be learning about the role of the pharmacist, the next I would be taking a history within the Pain and Symptom clinic. My time consisted of one-on-one experiences with health professionals, observing team-based care, and hands-on clinical experience. When I was working with a physician, I functioned in the familiar role of a medical student, but when assigned to another discipline, I acted as a student of that discipline. This not only allowed me to recognize the different roles but also the unique culture of each discipline. Just like medicine, each profession’s culture is influenced by their training and scope of practice and consists of a specific language and standards. I believe this insight will enhance my ability to work collaboratively in the future.

I had several opportunities to sit with one patient during an initial team consultation. I observed how each health care professional adapted their assessments to avoid unnecessary redundancies. I was surprised by the manner in which patients disclosed different details to each person. Sometimes this was reflective of a specific professional’s scope of practice; for example, only the pharmacist delved deeply into herbal supplements. Other times this was a direct consequence of the personality of the team member and often resulted in identification of important psychosocial issues. It was incredible to see how each discipline’s perspectives came together at the team conference to reach agreement on a comprehensive supportive care plan.

One of the invaluable aspects of the Studentship was the placement with another student. We attended some clinics together and some separately. We were able to learn from each other and appreciate the other’s perspective. Independently, we could develop a full understanding of the issues without being influenced by the other. In subsequently sharing interesting experiences, our learning doubled. The friendship that developed provided emotional support necessary for interacting with terminal patients. As a result, out of all the disciplines I encountered, I feel I now have the greatest understanding of the role of a dietitian.

Reflections—supervising oncologist’s perspective

In interacting with the students in various settings, it became apparent that the potential impact of the Studentship had been underestimated. Their depth of reflection and internalization of their experiences led to debate around such essential psycho-oncology topics as the appropriate time and way to discuss prognosis. We grappled together with whether it is ever acceptable to show emotion with patients and whether identifying with a patient or family member makes your job easier or harder. The end-of-rotation presentations displayed a degree of patient-centered understanding significantly greater than had been expected. This also confirmed how powerful direct patient interaction can be.

The evidence of their critical analysis is especially gratifying. Although MDT practice has intuitive benefits, there are drawbacks, which did not escape these students’ watchful eyes. Our students lived the advantages and disadvantages of an MDT-based approach to physical and psychosocial care, rather than just being lectured on them. After discussing various encounters, reacting to them, and contemplating the implications, our students were able to reach their own conclusions. They asked: what is not working about this situation? What can be improved by the team? What are system-wide barriers we must work within? Are there ever situations in which it is not necessary to work within teams? They demonstrated not only an appreciation for the advantages of integrating collaboration into clinical practice, but also an understanding of the contemporary challenges.

Challenges—clinical nutrition student’s perspective

Working on an acute inpatient care unit, or in any health care setting, is a lesson in priorities: yours, the physicians’, the nurses’, the patients’. These priorities often compete resulting in adequate, not optimal, care. A personal challenge for me was to overcome expectations created by previous clinical interactions, in which I learned to expect that other professionals did not want to discuss my recommendations. However, this Studentship proved that this does not need to be the norm.

The placement was not without some minor challenges. While I gained a great deal from the direct experiential format, 6 weeks is an extremely short period of time and there were some programs at the CCI which did not operate in the summer. I would have appreciated the opportunity for more involvement with patient support groups, for example.

Challenges—medical student’s perspective

Prior to completing the Studentship, I viewed multidisciplinary teams as an appropriate solution to increasing patient complexity and rising health care costs. Throughout my 6 weeks, however, I began to appreciate their challenges. It is challenging to determine at what point during a patient’s disease trajectory certain MDT members should become involved. If disciplines are only introduced when the need becomes significant, the window of opportunity for proactive risk reduction has been lost. However, if the patient meets every discipline at an initial consultation, when they may or may not be required, resources may be used inefficiently and the patient may be further overwhelmed increasing their psychological burden.

Another challenge is defining scope of practice and delegating specific tasks to each team member. This process requires particular coordination when multiple providers are capable of accomplishing the same task. The team must develop a standardized approach in which essential elements of each assessment are combined. However, through this approach, some team members may be denied the opportunity to practice skills that are part of their professional identity. Differences in opinion regarding best management practices may not be uncommon in a MDT.

Finally, an aspect of MDT practice which should not be overlooked is the limited amount of supporting evidence [7]. In theory, multidisciplinary care should increase provider satisfaction, improve patient outcomes, and decrease health care costs. It is therefore important to continue to participate in research to determine the efficacy of care provision by MDT.

Challenges—supervising oncologist’s perspective

The more competing priorities for the time of the clinical mentors, the more difficult it can be to model excellent MDT practice and inter-professional communication. As no health care professional can be perfect, students were exposed to suboptimal patient encounters, and these teachable moments are also beneficial. Another challenge for the clinical preceptors was ensuring that cross-discipline exposure did not result in passive observation. Preceptors may not have had direct responsibility previously for instructing trainees of different disciplines. With two students at different points in their training, with different backgrounds, a tailored approach to each was required, as well.

Lasting impressions—clinical nutrition student’s perspective

It is challenging to communicate the scope of impact this experience has had on me, both as an individual and as a dietitian who hopes to work in cancer care in future. One of the key lessons learned is that my role as a health professional transcends care of only physical symptoms. We have the ability to positively impact our patients’ lives on a daily basis by such simple things as active listening and encouraging questions [3]. Cancer is a profound part of someone’s life regardless of the outcome and instrumental in that are the professionals who support them during their journey. The knowledge and experience I gained has already impacted how I will interact with others in the future.

Lasting impressions—medical student’s perspective

I believe that many health care professionals, regardless of discipline, innately wish to be the sole provider of care. However, as I approached the end of my 6 weeks, I realized the quality of care my patients would have if I were to work independently. No matter how thorough my patient histories are, I would only obtain part of the story. No matter how diligent my studies, there would always be questions I could not answer. No matter how supportive I tried to be, there would always be needs I could not meet. A MDT is the best way to prevent these shortcomings. I know I cannot interact with patients as any other professional than a physician, but as a result of this experience, I do hope to view my future patients’ needs as other disciplines might. I can now recognize more than just medical problems and can better anticipate which disciplines should be involved. I also believe that my appreciation of the unique perspectives of other different health disciplines provides a framework upon which to develop future professional relationships.

Lasting impressions—supervising oncologist’s perspective

No matter how high my expectations were, these two students have far surpassed them in demonstrating the depth of their understanding of Supportive Care. I believe that care of their future patients will be improved by this experience. I hope they will become passionate advocates for patient-centered care and will continue to see through patients’ eyes.