A whole-process management intervention to transform pessimistic attitudes toward cancer care among internal medicine residents

Abstract

Background:

In China, improved cancer survival contrasts with persistent pessimistic attitudes among clinicians, which impacts care quality. We developed a “Whole-Process Management” (WPM) training program to bridge this gap by reshaping internal medicine residents’ understanding of the cancer care continuum.

Objective:

To investigate whether a WPM clinical training strategy can transform pessimistic attitudes toward cancer care and foster a more integrated understanding of palliative therapy among internal medicine residents.

Design:

A pre-post study utilizing semi-structured interviews. Responses were coded using a predefined categorical framework (positive/negative/NA) and compared before versus after the intervention to characterize internal medicine residents’ attitudinal shifts regarding cancer curability, treatment toxicity, and the role of palliative care within the cancer care continuum.

Methods:

Fifty-seven junior internal medicine residents undergoing oncology rotation at a university-affiliated hospital (January 2022–January 2023) received the WPM intervention. This novel training employed longitudinal patient case tracking and structured reflective seminars to help internal medicine residents view cancer as a chronic condition that can be actively managed.

Results:

The WPM program significantly reduced pessimistic attitudes. Internal medicine residents recognizing patients in good physical condition increased from 26% to 81% (p < 0.001). Perceptions of treatment toxicity (53% vs 4%), ineffectiveness (75% vs 4%), and expense (84% vs 7%) substantially decreased (all p < 0.001). Awareness of tumor curability improved from 5% to 79% (p < 0.001). The program also improved attitudes toward palliative care: understanding of hospice care principles increased from 0% to 75% (p < 0.001), willingness to consider hospice care for terminal patients rose from 21% to 84% (p < 0.001), and willingness to prescribe opioid analgesics increased from 9% to 93% (p < 0.001).

Conclusion:

The WPM clinical training strategy effectively addresses pessimistic attitudes by transforming internal medicine residents’ clinical perspective from isolated tasks to the patient’s entire journey, thereby enhancing their ability to provide integrated palliative and anti-cancer care.

Plain language summary

Transforming pessimistic views on cancer care: A new training for doctors

(i) What is already known?

In China, despite significant improvements in cancer survival rates, many clinicians—particularly those not specialized in oncology—hold persistently pessimistic views about cancer treatment. This mindset, which often underestimates the benefits of modern therapy and the potential for long-term disease management, can negatively impact patient care. Traditional medical training, which is often fragmented and task-oriented, does little to bridge this gap between reality and perception.

(ii) What does this paper add?

This study introduced and evaluated a novel “Whole-Process Management” (WPM) training program for junior internal medicine residents. The program used longitudinal patient tracking and reflective seminars to shift the internal medicine residents’ perspective from seeing cancer as a terminal disease to understanding it as a manageable chronic condition across the entire care continuum.

The results demonstrated a profound positive shift in attitudes. After the training, internal medicine residents were significantly more likely to recognize the potential efficacy and curability of cancer treatments. Furthermore, the program led to a dramatically improved understanding and acceptance of palliative care principles, including a greater willingness to provide hospice care and appropriately manage cancer-related pain.

(iii) What are the implications for practice?

The WPM training strategy effectively counters therapeutic pessimism by reframing how doctors-in-training view the cancer journey. This approach fosters a more integrated and proactive clinical mindset, equipping them to better combine anti-cancer therapy with palliative care. Implementing such educational models more broadly could be key to aligning physician training with the realities of modern, chronic cancer care.

Introduction

Cancer treatment has evolved into a complex and prolonged process as cancer survival has significantly improved in China, with the 5-year relative survival rate increasing from 30.9% in 2003–2005 to 43.7% in 2019–2021.^1,2 However, studies have shown that many clinicians, especially non-oncologists, remain pessimistic about patient prognosis and underestimate the long-term benefits of modern therapy. One study found that 59% of non-oncologists provided pessimistic survival estimates for advanced cancers, with 37% of responses underestimating median survival by more than 1 year. ³ Another study reported that non-oncologists accurately estimated survival for only 2 out of 12 common cancers, compared to 4 among oncologists, and were significantly more pessimistic in estimating survival for stage IV breast cancer. ⁴ These pessimistic mindsets are often driven by fear of the cancer situation, hopelessness, stigma, and personal, overwhelming cancer-related experiences.^5,6 Cancer remains the most feared disease in modern society, and myriad myths and biases related to cancer pervade both patients’ and professionals’ ideas. Even in trained professionals, personal experience is a stronger form of attitude than formal education, so pessimistic expectations may persist when lived experience outweighs formal training. ⁵ Patients with cancer often experience impairments in physical and psychological well-being, ⁷ which may also contribute to an emotionally charged clinical context for physicians. At the same time, although these pessimistic attitudes stem from fear and hopelessness, they are not merely emotional states in clinical practice; they are also cognitive discrepancies that come from disproportionate clinical exposure. Clinicians who lack exposure to the longitudinal trajectory of cancer care may form prognostic expectations largely from inpatient encounters, which disproportionately involve acutely ill patients with cancer-related complications; such an imbalanced exposure may contribute to underestimation of survival, ⁸ and consequently, the long-term benefits of modern anti-cancer therapy.

As cancer survivor requires more and more comprehensive and coordinated care similar to that needed for other chronic health conditions, ⁹ the gap between improved survival and clinicians’ outdated perceptions becomes increasingly apparent, underscoring the need for training models aligned with this reality. However, current residency training did not sufficiently address this perceptual disparity in cancer treatment. Current residency training remains task-oriented and compartmentalized, prioritizing protocol completion over cultivating cross-specialty competencies and holistic cancer care. This narrow focus, combined with insufficient training in communication and ethics, ¹⁰ leaves trainees ill-equipped for longitudinal patient management and the psychosocial dimensions of oncology practice. For example, palliative care services—a key component of holistic management—remain extremely scarce across mainland China, ¹¹ and one study reported that 68.8% of Chinese oncologists had received no formal palliative care training. ¹² Such limitations reflect a broader educational gap in understanding cancer as a chronic, evolving condition requiring longitudinal management. As a result, many physicians have limited experience with the full spectrum of cancer care, reinforcing their tendency to adopt pessimistic or overly cautious therapeutic attitudes.

To overcome these limitations, there is a growing need for training models that help clinical practitioners build an integrated understanding of cancer as a long-term, continuously managed condition. Previous educational interventions achieve this goal through distinct yet complementary approaches. Existing models include longitudinal palliative care co-management in fellowship training, ¹³ longitudinal communication curriculum embedded in oncology training, ¹⁴ reframing complication-focused teaching to reduce prognostic pessimism and inappropriate care withdrawal in internal medicine (IM) residents, ¹⁵ and elective hospice/palliative care rotations spanning inpatient and home-hospice settings. ¹⁶ However, few interventions are designed for time-limited oncology rotations for IM residents to recalibrate therapeutic expectations by reconstructing the entire cancer trajectory as a manageable continuum—an educational gap that motivated the development of our Whole-Process Management (WPM) training program. Unlike traditional models that isolate different phases of care, WPM emphasizes the patient’s entire journey. WPM is defined as a continuous, high-quality management model that accompanies patients throughout the entire diagnostic and therapeutic course—from admission to discharge, follow-up, and rehabilitation—providing uninterrupted and coordinated care. ¹⁷ By helping IM residents integrate therapeutic objectives with the evolving needs of patients, this approach aims to transform their perception of cancer from an inevitably terminal disease to a continuum that can be managed proactively and compassionately.

To investigate whether a WPM clinical training strategy can transform pessimistic attitudes toward cancer care and foster a more integrated understanding of palliative therapy among IM residents, we conduct this study.

Method

Study setting

This study was conducted in the Department of Medical Oncology at a university-affiliated hospital from January 1, 2022 to January 31, 2023. The hospital is a standardized residency training base in China, recruiting hundreds of medical residents annually for national standardized training programs. ¹⁰ The IM residency program spans 33 months, which includes a 1–2 months mandatory clinical rotation in the Department of Medical Oncology. Before beginning a new specialty rotation, IM residents attend lectures on common diseases and departmental responsibilities. During clinical training, attending physicians supervise their daily work and learning. Residents also participate in 4–6 educational activities per month, such as clinical ward rounds, case discussions, lectures, and skill training. Assessments are conducted upon completion of each rotation. Regarding clinical training in medical oncology, the instructors supervise the IM residents’ performance in invasive procedures and give lectures focusing on fundamental concepts of medical oncology, covering topics such as the three-step ladder drug therapy for cancer pain relief, ¹⁸ side effects of immunotherapy and chemotherapy, and mechanisms of antitumor drugs.

Participants

A total of 57 junior IM residents participated in this study during their medical oncology rotation from January 1, 2022 to January 31, 2023. This sample size was felt to be appropriate and has been shown previously to be sufficient for a longitudinal intervention study. ¹³ All participants were directly recruited by attending physicians of medical oncology during rotation. The inclusion criteria were as follows: IM residents from our center who rotated through the Department of Medical Oncology; IM residents were able to participate in the scheduled teaching activities and research assessments during the rotation. The exclusion criteria were as follows: IM residents who had previously participated in a psychological intervention or a similar structured clinical training curriculum; IM residents who withdrew from the study or withdrew consent; and IM residents who did not attend either the mid-point seminar or the final assessment (attendance at both was required). Of 64 IM residents approached, 57 (89.1%) were eligible and enrolled, and 7 (10.9%) were not included due to scheduling conflicts.

Prior to the intervention, written informed consent was obtained from all participants. All 57 IM residents received and completed the WPM-based training intervention, with full retention throughout the study period. A pre-post study design was implemented to evaluate the program’s effectiveness in reshaping attitudes toward cancer care.

Development and implementation of the WPM-based training program

After investigating the confusion and pessimistic attitudes among IM residents during clinical training in the Department of Medical Oncology, our multidisciplinary oncology education team developed a new clinical training program. The new strategy was rooted in the WPM perspective, aiming to reshape IM residents’ understanding of the entire cancer care continuum and bridge the gap between improved cancer survival rates and clinicians’ perceptions. This was achieved through its core innovation, the “WPM Oncology Training Module,” which employed retrospective, longitudinal case tracking and structured seminars to help IM residents build an integrated understanding of cancer as a long-term, managed condition. The curriculum was conducted alongside IM residents’ clinical duties, allowing them to seize potential learning opportunities in the work environment. ¹⁹

Case selection and tracking

Residents, working in small groups of 2–5, were assigned 1–2 de-identified patient cases from a consecutively sampled pool of patients who had completed their initial primary treatment and were in follow-up or ongoing management. This sampling strategy was designed to capture a representative profile of patients entering a phase of chronic care or surveillance, rather than artificially selecting for long-term survivors. With written consent and after full de-identification, all cases were able to be used for clinical teaching. Following a structured approach, IM residents reconstructed the patient’s journey from diagnosis through various treatment lines and follow-up, documenting the evolution of treatment goals, performance status trends, management of symptoms and comorbidities, and interventions related to quality of life.

Structured reflective seminars

The data tracking was supported by two facilitated seminars grounded in WPM principles.

• (1) Mid-point seminar: “Navigating the Cancer Care Continuum.” Here, groups shared initial findings from their WPM tracking. Facilitators guided discussions to help IM residents identify how treatment goals evolved over time and how different supportive interventions contributed to patient care at various stages, thereby reinforcing the WPM concept of continuous, coordinated management.

• (2) Final seminar: “The Patient Journey: Insights From WPM.” Each group presented a comprehensive overview of their tracked patient’s journey, using a visual timeline that integrated treatment phases, symptom control, and quality-of-life data. The focus was on articulating how a WPM perspective revealed the compound value of coordinated care over time.

Throughout this process, instructors acted as facilitators, helping IM residents interpret the data through a WPM lens. For patients with early-stage cancer, instructors introduced the clinical usage of tumor screening tests, the significance of neoadjuvant and adjuvant therapy, principles of surgery and radiotherapy, guidelines for survivorship, patient follow-up, and evidence of reduced cancer-related deaths. For patients with advanced cancer, instructors focused on treatment modalities including chemotherapy, targeted therapy, immunotherapy, radiotherapy, and local active treatment, while also addressing the management of adverse events. Within this therapeutic context, palliative care was integrated into the curriculum as a key component of the holistic management emphasized by WPM. Instructors explained that palliative care focuses on the optimal treatment for patients’ discomfort symptoms while involving psychosocial-spiritual care according to the needs, values, beliefs, and cultures of patients and their families, aiming to anticipate, prevent, and alleviate pain and improve the quality of life for patients with cancer, and to treat complications during anti-cancer treatments. ²⁰ Specifically, instructors detailed that palliative care emphasizes the relief of cancer-related symptoms, ²¹ proper readjustment of the principles and goals of the treatment of comorbidities, ²¹ potential cancer-related symptoms and preventive measures, ²² assessment and application of nutritional support,^21,23 psychological and social support,^21,24 and psychological support and health education for cancer caregivers. ²⁴

A key component was demonstrating the potential for success even in advanced disease. For patients with potentially curable advanced tumors, reducing tumor burden using radiotherapy, chemotherapy, and/or targeted therapy makes aggressive treatments with curative intent applicable.^25,26 Complicated situations were also discussed. The development of immunotherapy and targeted therapy is therapeutically valuable for terminally ill patients. Some tumors, such as malignant lymphoma and acute leukemia, can be cured with chemotherapy, ²⁷ while others, such as brain metastasis of lung cancer and hormone-sensitive breast cancer, can be treated with precisely targeted therapy. Through case-based discussions, instructors emphasized how modern therapeutic approaches could achieve meaningful outcomes across the disease spectrum, thereby reinforcing IM residents’ confidence in managing advanced cancer.

Data collection and interviews

To avoid potential response bias and inaccuracy in self-reported questionnaires and secure a response rate, semi-structured individual interviews were conducted with all participants before and after completing the WPM-based training intervention to evaluate attitudinal changes. The interviews examined five core aspects: (1) perceptions of cancer patients’ physical and mental states, (2) views on anti-cancer therapy, (3) perspectives on life-supportive interventions for terminal patients, (4) approaches to opioid analgesic prescription, and (5) understanding of hospice care (Supplemental Appendix 1). Interviewers recorded responses according to a predefined categorical framework without prompting specific answers.

The individual interviews were conducted before IM residents’ enrollment and at the end of clinical training in the medical oncology department. Y.F.X., J.L.X., K.X.Z., X.Y.W., and X.L. conducted the interviews. Each interview was evaluated by at least one oncologist and one specialist in IM or general practice in our multidisciplinary oncology education team, who were experienced and professional instructors. Before the initial interview, the interviewers were unaware of the participants’ identities. A standardized blinding process was implemented to enhance confidentiality. Interviewers were not involved in participants’ supervision or assessment. For each participant only, study IDs were used; two experts were randomly assigned as interviewers. They conducted semi-structured telephone interviews together, focusing on the five core aspects. During the interview, they maintained original notes independently and categorized the participants’ perspectives on each domain as positive, negative, or not applicable, noting a brief justification. Following this, their independent classifications were compared. All instances of disagreement were referred to a third, senior medical oncologist for final adjudication. To ensure consistency in assessing the IM residents during the interviews, all interviewers underwent several rounds of training by interviewing IM residents before the initiation of this study.

Statistical analysis

The differences in general knowledge and confidence in medical oncology and palliative care were compared for the participants before and after the training. Categorical variables were summarized as numbers (percentages). For each interview item, the distribution of responses (positive/negative/NA) before versus after training was compared using the Pearson chi-square test. When the chi-square approximation was not reliable (i.e., any expected cell count <1 or >20% of expected counts <5), two-sided exact p values were obtained using Fisher–Freeman–Halton exact test. We conducted all statistical analyses in R, version 4.2.0 (R Foundation for Statistical Computing, Vienna, Austria). p < 0.05 was considered statistically significant.

Results

Basic characteristics

Of the 57 IM residents who participated in the study, 21 (37%) were male, and 36 (63%) were female (Table 1). Prior to entering the WPM-based training program, around 70% of the IM residents thought that patients with cancer were unable to take care of themselves, hopeless, and depressed. In addition, 53%, 75%, and 84% of the IM residents thought anticancer therapies were toxic, ineffective, and expensive, respectively, while 84% of the IM residents had little knowledge of palliative care. Before the clinical training, 70% of the participants reported thinking that life-supportive interventions, such as mechanical ventilation, breathing tubes, and continuous intravenous medications, should be administered to patients with unstable vital signs in the terminal stage of cancer if the patient’s family does not request removal. Moreover, before training, 88% of the participants were unwilling to administer opioid analgesics to patients with cancer-related pain or preferred short-acting injections (Supplemental Appendix 2 and Figure 1). These baseline findings reflected the generally pessimistic views among IM residents before the WPM intervention.

Table 1.

Demographic information of IM residents.

Items	Total no. (%)
Gender	n = 57
Female	36 (63)
Male	21 (37)
Duration of training	n = 57
1 month	45 (79)
2 months	12 (21)

Figure 1.

The findings from individual interviews. Changes in residents’ attitudes are as follows. (a) The physical and mental state of most patients with cancer: α. Unable to take care of themselves (p < 0.001); β. Hopeless and depressed (p < 0.001); γ. Good performance scores (p < 0.001); δ. Strong desire to survive and achieve prolonged disease control (p < 0.001). (b) Mostly anti-cancer therapy: α. Toxic for patients with late-stage tumors (p < 0.001); β. Ineffective for patients with late-stage tumors (p < 0.001); γ. Expensive (p < 0.001); δ. Advanced tumors may be potentially curable (p < 0.001); ε. Early-stage tumors could be curable (p = 0.87); ζ. Have a general idea about anti-cancer therapies (p = 0.22). (c) Life-supportive interventions for patients with unstable vital signs in the terminal stage of cancer: α. They should receive (p < 0.001); β. It is worth considering hospice care (p < 0.001); γ. Treatments of life-supportive interventions administered to patients with cancer should be selected based on the aim of the anticancer therapy (p = 0.06). (d) The prescription of opioid analgesics: α. Willingness to provide a prescription to manage cancer pain (p < 0.001); β. Referring patients to the Department of Medical Oncology (p = 0.55); γ. Preference for short-acting opioids rather than long-acting opioids (p = 0.01); δ. Being afraid of administering opioid analgesics (p < 0.001). (e) Understanding of hospice care: α. Having an understanding of fundamental hospice care principles and expressing a preparedness to identify suitable patients for this type of care (p < 0.001); β. Understanding fundamental hospice care principles but lacking the ability to select suitable patients for this type of care (p > 0.99); γ. Understanding fundamental hospice care principles without having sufficient knowledge on basic treatment and patient selection (p = 0.02); δ. Just heard about “hospice care.” Pos indicates a positive opinion; Neg indicates a pessimistic view; NA indicates that the resident did not mention this issue. P values are two-sided. Pearson’s chi-square test was used when appropriate; otherwise, Fisher–Freeman–Halton exact test was used.

*p < 0.05. **p < 0.01. ***p < 0.001.

Eliminating pessimistic view in medical oncology

Compared with the attitudes before their enrollment, most of the IM residents changed their pessimistic view toward patients with cancer and anticancer therapy. After clinical training, they realized that most patients receiving anti-cancer therapy were in good physical condition and had a strong desire to survive and achieve prolonged disease control (before 26% vs after 81%; p < 0.001). Fewer IM residents thought that most anti-cancer therapies were toxic (before 53% vs after 4%; p < 0.001), ineffective (before 75% vs after 4%; p < 0.001), and expensive (before 84% vs after 7%; p < 0.001) for patients with late-stage tumors. Meanwhile, more IM residents acknowledged that advanced tumors could be potentially curable (before 5% vs after 79%; p < 0.001; Supplemental Appendix 2 and Figure 1).

Changing attitudes toward palliative care

After the training, the IM residents grasped the basic concept and value of palliative care. An increased proportion of IM residents demonstrated an understanding of fundamental hospice care principles and expressed a preparedness to identify suitable patients for this type of care (before 0% vs after 75%; p < 0.001). More IM residents were willing to consider hospice care for patients in the terminal stages of cancer (before 21% vs after 84%; p < 0.001; Supplemental Appendix 2 and Figure 1). After the training, in addition to referring patients to the Department of Medical Oncology, most participants recognized the value and principles of cancer-related pain management. They were significantly more likely to prescribe opioid analgesics to patients with cancer pain (before 9% vs after 93%; p < 0.001), while fewer IM residents were afraid of administering these drugs (before 79% vs after 4%; p < 0.001) or preferred short-acting opioids only (before 53% vs after 26%; p = 0.01; Supplemental Appendix 2 and Figure 1). In summary, these findings indicate a marked shift in perspective, from an initially pessimistic and cautious outlook to an informed recognition of the value and appropriateness of modern anticancer and palliative interventions.

Discussion

Our study found that a training program based on “WPM” successfully reduced pessimistic attitudes toward cancer patients and anti-cancer therapy among junior IM residents and improved their understanding and acceptance of palliative care. This change in views—on treatment toxicity, efficacy, cost, and even the potential curability of advanced cancer—shows that education can help align clinicians’ mindsets with the modern reality of cancer as a chronic condition.

Our findings are consistent with the discovery of prior educational models, showing that repeated longitudinal clinical exposure can reshape how trainees think and act in clinical practices, which is especially important when it comes to continuous cancer management. Bauman et al. established a longitudinal palliative care educational model in hematology-oncology fellowship training. Through co-managing their own continuity patients alongside palliative care specialists in concurrent clinic visits, trainees reported improved palliative care knowledge, skill confidence, and described the experience as highly meaningful for their clinical practice. ¹³ Vern-Gross et al. implemented a longitudinal communication curriculum for oncology trainees. They integrated simulation, reflective writing, and structured feedback into clinical training workshops to develop conversation skills essential for coordinated cancer care. ¹⁴ Lycan et al. discovered that changing the emphasis from complication-focused to prognosis-focused in IM residents’ training can reduce inaccurate negative biases and prevent inappropriately withdrawing care for patients with potentially treatable conditions. ¹⁵ Von Gunten et al. developed an elective hospice and palliative care rotation for IM residents across inpatient and home-hospice settings, and demonstrated improved end-of-life care knowledge and communication skills after the rotation. ¹⁶ In our study, we offer a more practical approach that provides a structured framework and repeated opportunities to help IM residents revisit the cancer trajectory. Even without a longitudinal cancer management experience alongside palliative care specialists, a longitudinal communication curriculum, or a standalone hospice rotation, the WPM approach appears to support broader conceptual gains across domains central to coordinated cancer care, including attitudes toward anti-cancer therapy, life-support decisions, opioid use, and recognition of hospice care.

The WPM model reshapes clinical reasoning by changing how IM residents learn. Traditional training is often compartmentalized and fails to show the full cancer journey. In contrast, WPM uses longitudinal case tracking and reflective seminars. This allows IM residents to see how treatment goals change over time and how continuous, coordinated care adds value. Shifting their focus from isolated tasks to the overall patient journey is key to changing their attitudes. By translating the abstract idea of holistic care into a structured, teachable curriculum, WPM provides a practical framework for standardizing cancer education and preparing non-oncologists to manage cancer as a long-term condition.

Our intervention also led to improvements in the understanding of pain management and palliative care. Chronic pain is highly prevalent among patients with cancer, and effective cancer-related pain management is critical for ensuring a good quality of life for patients with cancer. ²⁸ IM residents’ restricted prescribing authority—and the formal credentialing often required for controlled opioid analgesics—limits their opportunities to gain hands-on experience with real-world cancer pain management. Most Chinese physicians believe that their medical school and residency training in cancer pain management were inadequate. ²⁹ Our study suggests that longitudinal case-based learning may strengthen IM residents’ willingness to engage in cancer pain management. Palliative care has a major impact on end-of-life outcomes and overall survival in cancer patients. ³⁰ However, in China, palliative care is still not widely integrated into routine clinical practice. Cultural factors, such as the view that mentioning death is disrespectful, can complicate communication and care delivery. Chinese individuals believe the word “death” brings bad luck, and their refusal to discuss any death-related topics always hinders the implementation of palliative care services. ³¹ Meanwhile, the quality of palliative care is low, partly due to a shortage of trained health professionals. ³² Formal palliative care training is not widely available in medical schools, ³³ and many healthcare workers, including oncologists, lack sufficient knowledge. ³⁴ Our WPM program integrated palliative care as a core component, emphasizing symptom control, psychosocial support, and pain management within the broader goals of anticancer therapy. This approach helped correct the misconception that palliative care is only for the end of life.

Nevertheless, this study has some limitations. The data were collected from a single residency program, which may limit generalizability. The participants, despite our recruitment effort, were postgraduate medical students from our own college, limiting the diversity of the participant pool. In addition, the use of interviews as a primary method of assessing attitudes and knowledge limited consistency and accuracy among examiners. Despite holding preparatory practice interviews with non-participant IM residents, we did not implement a formal pilot testing of the interview guide; thus, the robustness of our interview protocol and the full elimination of potential biases cannot be ascertained. Also, the study did not conduct a prior sample size calculation; the participant number was based on practical feasibility and previous longitudinal intervention. ¹³

Future research should investigate whether the WPM intervention improves IM residents’ palliative care skills and knowledge, in addition to attitudinal changes. This approach essentially functions as a structured preclinical exposure, allowing medical residents to navigate specialized clinical situations through guided simulation. While effective in shifting pessimistic attitudes—a critical yet isolated training objective—the paradigm invites extension. Future innovations could translate this exposure model into more efficient and flexible formats, such as artificial intelligence (AI) driven simulations, to cover a wider spectrum of clinical situations. Emerging evidence from technology-enhanced medical education suggests that innovative instructional tools may reduce learners’ mental workload, promote more positive emotional experiences, ³⁵ and therefore improve acceptance of training. However, the integration of such AI tools must be carefully designed to preserve the primacy and quality of the therapeutic alliance ³⁶ and to accommodate the spectrum of attitudes clinicians hold toward AI-assisted care. ³⁷

Conclusion

The “WPM” clinical training strategy addresses pessimistic attitudes among IM residents by transforming their clinical perspective from isolated tasks to the patient’s entire journey. This shift fosters a more realistic understanding of cancer care and helps them appreciate the role of integrated palliative care. Cultivating this more accurate and proactive mindset is crucial for managing cancer as a chronic condition.