The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040 .1

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040 .1

82 Background: Palliative radiation therapy (RT) for painful bone metastases is underutilized in the United States (U.S.), perhaps due to inappropriate use of multi-fraction (MF) regimens over more convenient, less costly, and equally effective single fraction (SF) regimens. Practice patterns may change with improved knowledge of radiation oncology residents (ROR) and non-radiation oncology physicians who refer patients for palliative RT. The aim of this study was to provide evidence-based educational content to these groups, and assess knowledge and views before and after. Methods: In April - June 2017, an electronic educational tool was sent to medical oncology and palliative care physicians, and ROR in the U.S. Multiple choice questions assessed knowledge, and were followed by evidence supporting the correct answer. Likert and sliding scales gaged tool impact. Chi-square and Mann-Whitney tests compared groups and pre/post-test responses. Results: Responses were obtained from 109 (2%) referring physicians (RP) and 135 (21%) ROR. ROR had higher scores than RP for 8 of 9 objective questions. RP were less likely to know that SF and MF are equivalent in terms of pain response (64 v. 91%, p < 0.01) and subsequent analgesic use (86 v. 95%, p = 0.02), or that SF is associated with a higher retreatment rate (27 v. 93%, p < 0.01). ROR were less likely to know that SF and MF are equivalent for patients with a high likelihood of long term survival (25 v. 56%, p < 0.01). After viewing the content, ROR felt more knowledgeable [ mdn 3 (IQR 3 - 4) v. 4 (IQR 3 - 4), p < 0.01], and RP felt more empowered [ mdn 3 (IQR 2 - 4) v. 4 (IQR 3 - 4), p < 0.01]. RP found the survey more helpful, and knew less of the data prior [ mdn 50 (IQR 25 - 75%) v. 80% (IQR 66.3 - 90%), p < 0.01]. Despite knowing the data, ROR preferred SF less than RP at completion (67 v. 85%, p < 0.01). Conclusions: This study demonstrates a need for educational content for multidisciplinary providers on appropriate palliation of bone metastases. Despite ample knowledge, the bias of practicing radiation oncologists for MF is being passed onto residents. Greater knowledge may translate into more effective referral patterns and patient advocacy by RP, and potentially improve utilization of palliative RT in the U.S.

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