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Geriatric oncology training - educating the workforce of the future
Administrative and financial issues in
geriatric oncology education: a Brazilian example
Dr. Aldo L. Abbade Dettino, MD, PhD
Clinical Oncology dept.– Oncogeriatric Unit,A. C. Camargo Cancer Center (ACCCC), Sao Paulo, Brazil
PhD in Science (Pathology) – FMUSP/2008Post-graduation program – International Center for Research and
Education (CIPE)-ACCCC. Discipline: Therapeutic update to target therapy and translational
research.
SIOG 2015. 13/Oct/2015
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Geriatric oncology training - educating the workforce of the future
Disclosures (2013-2015):
none for this presentation
• 1. Honoraria: Astellas [lectures CRPC (enzalutamide)]; Bayer [speaker (Radium-223); AstraZeneca [lectures: lung (ITKs, gefitinib); breast (exemestane)]
• 2. Consulting/Advisory role: Janssen [CRPC (abiraterone)]; AstraZeneca [Lung (ITKs, gefitinib)].
• 3. Research funding (institutional): Astellas [CRPC, EAP (enzalutamide)]; Boehringer-Ingelheim, Pierre-Fabre[H&N (afatinib, vinflunine)]; Roche [gastric, pertuzumab]; Janssen [CRPC (abiraterone)]; Merck, AbbVie [lung (pembrolizumab, veliparib)];
• 4. Travel/accomodation expenses: Roche, Astellas, Pierre-Fabre, Sanofi, Janssen, Bayer.
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Geriatric oncology training - educating the workforce of the future
Presentation topics
• Importance
• Objectives – present and discuss:
– Needs and Challenges
• Experiences in Brazil
– Geriatric oncology education
• In our cancer center
• Feasibililty, difficulties
• Ideas and Perspectives
– Solutions?
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Geriatric oncology training - educating the workforce of the future
World population aging
http://esa.un.org/unpd/wpp/publications/files/key_findings_wpp_2015.pdfUnited Nations, Department of Economic and Social Affairs, Population Division (2013).
World Population Ageing 2013. ST/ESA/SER.A/348.4
- Potential Support Ratio (PSR):
number of people aged 20 to 64 by
the number of people aged 65 and
over - (“workers/retiree”)
• Decreasing for most of the
countries. Health, social &
ECONOMICAL impact
- Health care systems + old-age and
social protection systems
• fiscal and political pressure
• countries are likely to face in the
not-too-distant future
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Geriatric oncology training - educating the workforce of the future
Problems
• Demands from elderly increasing population
• GO education importance: up-to-date field, in
many instancies.
• Despite knowledge gained, gaps in research,
education and assistance in GO. Remarkably,
administrative and financial factors interfere
with that.
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Geriatric oncology training - educating the workforce of the future
Needs• More health professionals and social
plans for elders vs. “shortage of geriatricians"
• More and more: – nurses, physicians, physical therapists,
nutritionists etc; personal trainers…
• Caregivers, providers
• Architectural places: living, socializing, educating, caring
• Education and research for assistances – pts, families and caregivers, instruct other areas
• Money $$$$
• ETC
Are we …6
(Faces – Tarsila do Amaral)
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Geriatric oncology training - educating the workforce of the future
Needs• More health professionals and social
plans for olders vs. “shortage of geriatricians"
• More and more: – nurses, physicians, physical therapists,
nutritionists etc; personal trainners…
• Caregivers, providers
• Architectural places: living, socializing, educating, caring
• Education and research for assistances – pts, families and caregivers, instruct other areas
• Money $$$$
• ETC
Are we preparing ourselves?7
(Faces – Tarsila do Amaral)
Geriatric oncology training - educating the workforce of the future
Challenges
Political and health service/hospital managers (+ours) - CHOICES:
• No focus in geriatric oncology and prevalent issues and worst end-points, more costs and less quality of life (and survival?)?
• Investments to be able to make a strong effort to provide more (quality of) life?
• Remaining period of life may be better, p.ex. with less toxicities from treatments and
• better support
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(Laurence Olivier Hamlet:
To be or not to be)Copyright: Gian Salero, shutterstock.com
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Geriatric oncology training - educating the workforce of the future
Challenges
Political and health service/hospital managers (+ours) - CHOICES:
• No focus in geriatric oncology and prevalent issues and worst end-points, more costs and less quality of life (and survival?)?
• Investments to be able to make a strong effort to provide more (quality of) life?
• Remaining period of life may be better, p.ex. with less toxicities from treatments and
• better support
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Geriatric oncology training - educating the workforce of the future
Geriatric societies concerns
• Geriatrician/elderly
– Brazil: 2014 - open letter to population
• 2010 – around 1:5000
• ~2014 - 1 geriatrician for 20 thousand elderlies (60+?) –ideal 1:1000? (Brazilian Society of Gerontology and Geriatrics/SBGG; 2250 associates).
– USA:
• 2015 - 1:2526 (75+)
• 2015 – geriatric psychiatrists – 1:11526
• Projected 2030 – 1:20448
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http://portal.cfm.org.br, 18/Sep/2014
http://www.americangeriatrics.org/advocacy_public_policy (acessed 11/Nov/2015)
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Geriatric oncology training - educating the workforce of the future
Education and gerontology: challenges
and opportunities
• Gerontology: exchange of ideas and data
• interdisciplinary and multiprofissional field:
– Biology, medicine, social sciences, psychology, for
examples.
– Interfaces - works of geriatricians, physical
therapy, nursing, social assistance, law, clinical and
educational psychology etc…
Cachione M, Neri AL. [Educação e gerontologia: desafios e oportunidades].
RBCEH - Revista Brasileira de Ciências do Envelhecimento Humano, Passo Fundo, 99-115 - jan./jun. 2004.
http://www.upf.br/seer/index.php/rbceh/article/view/49/56 11
Geriatric oncology training - educating the workforce of the future
Education in GO
• Objectives. Need strategies:
• discuss teaching and learning• how to optimize education, and deal with
administrative and financial issues.
• How? Describe administrative andfinancial topics:– implementation and maintenance
– interference and how to improve education andresearch
– Offer good-quality assistance, based on the regional experience of the GO team
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Geriatric oncology training - educating the workforce of the future
Different settings• public or private
• acute or intensive care unit
• ambulatory, nursery
• hospice, home care
• Assistance, administrative, or research view
• Clinical, imaging, pathological, molecular parameters
• Institutional; regional, national, worldwide; health services
and systems, politics
• Different needs, available time and staff; AND GOALS
{(neo)adjuvant, curative; palliative, QoL, survival etc}
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Extermann M. Cancer Res Treat. 2010;42(2):61-68
Wildiers et al. J Clin Oncol 2014;32:2595-603
Drukker et al. EJC 2014;50,1045– 1054
Geriatric oncology training - educating the workforce of the future
Administrative and financial issues in
GO education• POINTS OF VIEW - various
– Patient and caregivers/family
– Health professionals
– Health system, political system, economical context
– Assistance
– Education
– Research
• Different tasks, different payments vs. task
overlaps. Different objectives? How to integrate?
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Geriatric oncology training - educating the workforce of the future
Administrative and financial issues in
GO education• POINTS OF VIEW - various
– Patient and caregivers/family
– Health professionals
– Health system, political system, economical context
– Assistance
– Education
– Research
• Different tasks, different payments vs. task
overlaps. Different objectives? How to integrate?
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"The disintegration of the inner life hits the heart of human existence.
Our whole life and heart is devoted to developing our personality.
Geriatric oncology training - educating the workforce of the future
Integrated Oncogeriatric Approach (IOGA) Model.
Tremblay D et al. BMJ Open 2012;2:e001483
©2012 by British Medical Journal Publishing Group16
Integrated approach: administrative and
financial support too
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Geriatric oncology training - educating the workforce of the future
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Ideas from information technology
Networks must transform from complex hierarchies of fixed architecture into flat
standards-based topologies that are optimal for the any-to-any requirements of service
delivery.
Adapted from The transformation
from application delivery to service delivery.www.citrix.com (acessed 11/Sep/15)
Geriatric oncology training - educating the workforce of the future
`• Finances & COSTS – parallels with scholl and health
teaching programs
• Instructional expenditures
• Student/fellows and staff support
• Administration costs
• The “other” category
– http://www.greatschools.org/gk/articles/school-finance-issues/
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Geriatric oncology training - educating the workforce of the future
`• COSTS – parallels with scholl and health teaching programs
• Instructional expenditures:
– costs related to teachers/health professionals instructing students/fellows.
– salaries, supplies (textbooks, medias) and purchased instructional services,
libraries, curriculum development and training for staff/teachers.
• Student/fellows and staff support :
– funds spent on the cost of health, psychological, guidance and therapy
departments at a school/hospital. Staff support includes the cost of libraries,
media centers and training.
• Administration costs:
– includes expenditures for the administration of both schools and medical
programs.
– board of education, superintendencia, graduation expenses, central office
expenses such as budgeting, payroll, purchasing, planning and research.
• The “other” category includes all other types of expenditures.
– Examples of costs in this category include operations (utilities, maintenance
and security), food service, and the salaries of support staff.
http://www.greatschools.org/gk/articles/school-finance-issues/
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Geriatric oncology training - educating the workforce of the future
Our institutional recent numbers
(2014):
20Challenges >>>
• ~4,000 consultations /month in clinicaloncology
• ~10,000 pts / year
• ~ 2/3: 65+ years old.
• 20%: 70+ years old.
• Headquarter with 5 buildings; 1 near tower to publicand pediatric assistance, two satellite clinics in otherneighborhoods, 2 research and administrativecenters
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Geriatric oncology training - educating the workforce of the future
Our time line• Until 2009 – ideas
• 2009 – proposal, no administrative support yet
• 2010 – pilot phase – + 1 nurse and 1 psychologist
• 2011-3: more routine use of CGA – 2 nurses
• 2014: less adherence to CGA... Staff with multiple tasks, besides GO, such as pre-elective hospitalization(all ages); incresing volume. However:
• Some opportunities: previous data presentation (ESMO 2013, ASCO 2014), today´s opportunity (SIOG 2014)
• 2014: doctors and fellows, 2 nurses; other specialties referred inside the hospital (geriatric oncology unit, no formal geriatric expertise nearby).
[http://siog.org/images/SIOG_documents/Lisbon/f-dettino%20aldo.pdf]
• 2014-5/6 CHALLENGES:– Constraints: staff (dedicated), architectural space, heavy work
load
– Patient-family-health professional and institutional corporateneeds
– Care, research, education; administrative and financial issues
– How to convince fellows of the importance of topics vs. more work and more time demanded (complexities) vs. results andrevenues
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Geriatric oncology training - educating the workforce of the future
Procedures in numbers/y (all center)
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0
50'000
100'000
150'000
200'000
250'000
300'000
350'000
400'000
1 2 3 4 5
Ambulatorial attendances/2000 year
0
50
100
150
200
250
300
350
400
450
500
1 2 3 4 5
ICU (admissions)/2000 year
* increasing financial income at a rate of around 15%/year, 7% in 2015 so far, versus a
possible 2015 inflation of almost 10%
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Geriatric oncology training - educating the workforce of the future
Procedures in numbers/2000 years
23
0
10'000
20'000
30'000
40'000
50'000
60'000
70'000
80'000
90'000
1 2 3 4 5
Surgeries
Chemotherapies (sessions)
Hospitalizations
Geriatric oncology training - educating the workforce of the future
TORREHILDA
Beds over time: recent new towers 2012 & 2013
* 2015: maybe it will take at least 4-5 years to increase, due to architectural, administrative and
economical concerns
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Geriatric oncology training - educating the workforce of the future
Size of the staff – Clinical Oncology dept.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
4 4 4 4 4 46 6
8 8 810
15 1518
12 12 12 12 12 1214
1620
2224
26
33
40
48
9 9 9 9 10 1114 15 16 17
2125
3032 33
21 21 21 21 22 2328
3136
39
45
51
63
72
81
Residents 1st year Residents total Medical staff Total
25
Years 2000:
Geriatric oncology training - educating the workforce of the future
Size of the staff – Clinical Oncology dept.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
4 4 4 4 4 46 6
8 8 810
15 1518
12 12 12 12 12 1214
1620
2224
26
33
40
48
9 9 9 9 10 1114 15 16 17
2125
3032 33
21 21 21 21 22 2328
3136
39
45
51
63
72
81
Residents 1st year Residents total Medical staff Total
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Years 2000:
Strategic audience:
potentially more open-minded?
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Geriatric oncology training - educating the workforce of the future
From the Young SIOG mentorship program
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• Communication
• Collaboration - Join efforts
• Profit of societies and entities
experiences
• Know audiance: institution,
region, expertise, knowledge
• Technology – media reaching
• Innovation
• Diversification
• The future
THINK PAIR SHARE
Ideas – active young discussing people
� Partnerships with existing societies
� Connecting world and local institutions
� Opportunities of experiences with
mentors
� Gain experiences from researches in
GO, but also from other areas:
epidemiology, etc
� Open minded – youngs, mostly; needs
sponsorships – financial issue again
� Link of fellows with recently graduated
ex-fellows
� Repetition – change general medical
oncologists from non-believers
Geriatric oncology training - educating the workforce of the future
From the Young SIOG mentorship program
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• Communication
• Collaboration - Join efforts
• Profit of societies and entities
experiences
• Know audiance: institution,
region, expertise, knowledge
• Technology – media reaching
• Innovation
• Diversification
• The future
THINK PAIR SHARE
Ideas – active young discussing people
� Partnerships with existing societies
� Connecting world and local institutions
� Opportunities of experiences with
mentors
� Gain experiences from researches in
GO, but also from other areas:
epidemiology, etc
� Open minded – youngs, mostly; needs
sponsorships – financial issue again
� Link of fellows with recently graduated
ex-fellows
� Repetition – change general medical
oncologists from non-believers
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Geriatric oncology training - educating the workforce of the future
Ideas – face problems to better gains
• Healthcare programs for the elderly
• take into account the multi-dimensionality of health and social inequalities
• interventions can target the most affected elements of HRQOL as well as the most vulnerable subgroups of the population.
• Interventions for whomneed them.
• Improving QoL in mostcompromised situations
29
Lima MG et al. Cad. Saúde Pública [online] 2009; 25(10): 2159-2167
http://dx.doi.org/10.1590/S0102-311X2009001000007
Geriatric oncology training - educating the workforce of the future
Lessons from other
fields/specialties
• The Crossroads
of Geriatric Cardiology
and Cardio-Oncology.
• [Professional's
expectations to improve
quality of care and social
services utilization in
geriatric oncology]
Health professionals and
geriatricians
• skills and insights pertaining to
various specialists
• Key roles in defining care
Inform and enhance
key management expertise
Coordination of a multidisciplinary
and multi-professional intervention
Optimizing links between
professionals Improve care planning,
health and social services utilization.
Coordination effort, a better
organization of the clinical activity in
geriatric oncology, to optimize
clinical practice and global cares
30
Nguyen KLet al. Curr Geriatr Rep 2015;4(4):327-337
Antoine V et al. Bulletin du Cancer 2015;102(2):150–161
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Geriatric oncology training - educating the workforce of the future
Integrating Frailty into
Clinical Practice to
Prevent the Risk of
Dependency in the
Elderly.
• Epidemiological scenario – aging
• High healthcare costs for management of
dependent individuals - adoption of
strategies:
• preventing loss of physical function and
anticipate the take in charge of older persons
at risk of negative outcomes.
• Major medical specialties (e.g., oncology,
cardiology, neurology…) have already moved
to early stage of the diseases to be more
effective.
• Authors conclusion: Geriatric medicine must
do the same
• moving to frailty an early stage of
disability were intervention are more
likely to be effective.
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Vellas B. Nestle Nutr Inst Workshop Ser 2015;83:99-104
doi: 10.1159/00038209220
Geriatric oncology training - educating the workforce of the future
• “more research and
education of health
providers in certain
geriatric issues is required
for elderly patients.”
(Early-Stage)
Breast Cancer in
the Elderly:
Confronting an
Old Clinical
Problem.
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Dimitrakopoulos et al. J Breast Cancer 2015;18(3):207-17
doi: 10.4048/jbc.2015.18.3.207. Epub 2015 Sep 24
Ideas in some contexts
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Geriatric oncology training - educating the workforce of the future
Balducci. J Gastrointest Oncol 2015;6(1):75-8
Geriatric oncology training - educating the workforce of the future
Put some GO education in perspective• Difficult administrative, political & economical scenarios may happen, but
work must be done aiming to allow workers of the future to think and plan:
• PREVENT COMPLICATIONS - Detect predictive factors of complications in
oncological treatment. Room for screening?
• Prevent additional common complications in elderly: falls, polypharmacy,
undernutrition, depression, sarcopenia, for example.
• TREATMENT PROTOCOLS - Propose treatment protocols adapted to functional
capacity - avoid over and under treatment.
• REHAB - Offer ways to rehabilitation of reversible vulnerability and frailty, with
combined interprofessional work; & to treatment side effects.
• PSYCHOLOGIC AND COGNITIVE SUPPORT - Detect early signs of psychological
or cognitive alterations that may contribute to additional deficits.
• DIFFERENT SETTING SUPPORT, RESEARCH - Offer home, ambulatory and
hospital support to all patients, specially for the ones that cannot receive full
or specific cancer treatment (oncogeriatric palliative care).
• INTERDISCIPLINARITY
• ASSISTANCE, RESEARCH, then EDUCATING OTHERS – CYCLE RUNNING
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Geriatric oncology training - educating the workforce of the future
Put in perspective• Difficult political & economical scenario, but work must be done aiming to
allow workers of the future to think and plan for:
• PREVENT COMPLICATIONS - Detect predictive factors of complications in
oncological treatment. Room for screening?
• Prevent additional common complications in elderly: falls, polypharmacy,
undernutrition, depression, sarcopenia, for example.
• TREATMENT PROTOCOLS - Propose treatment protocols adapted to functional
capacity - avoid over and under treatment.
• REHAB - Offer ways to rehabilitation of reversible vulnerability and frailty, with
combined interprofessional work; & to treatment side effects.
• PSYCHOLOGIC AND COGNITIVE SUPPORT - Detect early signs of psychological
or cognitive alterations that may contribute to additional deficits.
• DIFFERENT SETTING SUPPORT - Offer home, ambulatory and hospital support
to all patients, specially for the ones that cannot receive full or specific cancer
treatment (oncogeriatric palliative care). Research.
• INTERDISCIPLINARITY - Combine assistance to comorbidities with the
oncology team, better GO interventions to better care.
• ASSISTANCE, RESEARCH, EDUCATING OTHERS – CYCLE RUNNING35
Geriatric oncology training - educating the workforce of the future
How to deal with uncertainty in
teaching/learning issues• Example:
• Integrating geriatric
assessment into
decision-making after
prostatectomy: adjuvant
radiotherapy, salvage
radiotherapy, or none?
36
Goineau A et al. Front Oncol 2015;5:227
doi: 10.3389/fonc.2015.00227. eCollection 2015.
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Geriatric oncology training - educating the workforce of the future
Geriatric oncology aspects
are part of a broader
complexity of health planning • Areas of
uncertainty: how
to (suggest)
teach(ing) patient-
centered
individualized
treatment?
37
Goineau A et al. Front Oncol 2015;5:227
doi: 10.3389/fonc.2015.00227. eCollection 2015.
Geriatric oncology training - educating the workforce of the future
Geriatric oncology aspects
are part of a broader web
of health planning factors
• Example:
• Integrating geriatric assessment into decision-making after prostatectomy: adjuvant radiotherapy, salvage radiotherapy, or none?
• Areas of uncertainty: how to (suggest) teach(ing) patient-centered individualized treatment
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Image: Patrick Pleul/AFP/Getty Images
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Geriatric oncology training - educating the workforce of the future
Progress and remaining challenges for cancer control
in Latin America and the Caribbean.
• Funds, insurance coverage, doctors,
health-care workers, resources, and
equipment - very inequitably
distributed between and within
countries.
• Previous scarcity of cancer registries
hampered the design of credible cancer
plans, including initiatives for primary
prevention.
• The Lancet Oncology asked for update
– Comission sceptical that they would
uncover much change.
Strasser-Weippl et al. Lancet Oncol. 2015;16(14):1405-38. doi: 10.1016/S1470-2045(15)00218-1. 39
• Funding for health care
& education:• small percentage of
national gross
domestic product
• Even smaller percentage
of health-care funds
diverted to cancer care
Geriatric oncology training - educating the workforce of the future
Progress and remaining
challenges for cancer control
in Latin America and the
Caribbean.
• Much progress made in short
time.
– structural reforms in health-
care systems,
– new programs for
disenfranchised populations,
– expansion of cancer
registries and cancer plans,
and
– implementation of policies
to improve primary cancer
prevention.
40
Strasser-Weippl et al. Lancet Oncol. 2015;16(14):1405-38. doi: 10.1016/S1470-2045(15)00218-1
Nelson R. Cancer Care Making Impressive Strides in Latin Americahttp://www.medscape.com/viewarticle/853622
Proportion of the regional population covered by high-
quality cancer incidence and mortality data.
Copyright © 2015 American Cancer Society,
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Geriatric oncology training - educating the workforce of the future
Conclusions and message
• Geriatric oncology education deals with
transdisciplinarity and complexities
• Local contextualization helps in defining
problems and priorities
• As medicine/sciences and (geriatric) oncology,
education has dynamic demands:
• For improvements, needs and challenges have
to be faced and overcome.
41
* To those interested in discussing more, visit other
posters and presentations – this theme #110; plus others
Geriatric oncology training - educating the workforce of the future
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Geriatric oncology training - educating the workforce of the future
Education, teaching and learning
• “Jack of all trades, master of none”
vs.
• “Talent is cheaper than table salt. What
separates the talented individual from the
successful one is a lot of hard work.”
43
Geriatric oncology training - educating the workforce of the future
Education in GO
• “Jack of all trades, master of none”
vs.
• “Talent is cheaper than table salt. What
separates the talented individual from the
successful ones is a lot of hard work.”
(Stephen King).
Thank you for your attention…
44
Geriatric oncology professionals
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Geriatric oncology training - educating the workforce of the future
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Thank you again for your attention
(and trying not to starve)…
Geriatric oncology training - educating the workforce of the future
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50°5'58.653"N, 14°23'22.81"E®
Thank you again for listening (and trying not to starve)…
Hope we may enjoy the this sunset in
Diplomat Hotel 9th floor again…
Try SIOG LATAM/S. Paulo, Brazil, Aug/2016
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