The end of year 3 in fellowship training marks the formal coming of age for hematologists and oncologists. Year 3 fellows must take their training and experience into the next stage. In the final year, research projects have to take shape and many fellows are beginning to develop an expertise in a chosen field. Will it be private practice, industry, academic medicine, government, or a nontraditional path?

Steve Rosinski, MD, PhD, senior fellow in the hematology/oncology division at the Fred Hutchinson Cancer Research Center in Seattle, believes that in the third year it is important for fellows to take ownership of their research project. Working with colleagues and mentors early on is important for learning how to use tools and assays, but ultimately research is the primary responsibility of the fellow. “Fellows should go from needing instruction and assistance on learning assays and not being the primary driver, to being the one troubleshooting and controlling their project,” said Dr. Rosinski. “They can still ask for assistance but ownership needs to be entirely the fellows.”

The hematology/oncology fellowship program at the Fred Hutchinson Center has a strong focus on research. The first 18 months include typical clinical training and are followed by 2 years of dedicated research training. Fellows are able to choose from basic investigative opportunities to clinical trial development. Dr. Rosinski noted that all of his time is spent working in the lab on his research project except for one half-day per week dedicated to a hematology/oncology clinic.

According to Dennis A. Priebat, MD, director of medical oncology at Washington Hospital Center (WHC) in Washington, DC, and program director for the hematology/oncology fellowship program, his fellows are granted 4 months of research in year 2 and 6 months in year 3. The final year includes 2 to 3 months of inpatient clinical rotations, as well as a few months of outpatient specialty rotations, chosen by each fellow. Fellows typically choose areas where they are looking to gain more experience. “By [the third year] a fellow should become independent when working in the clinical setting and be able to develop a well-formulated evaluation, management, and treatment plan,” said Dr. Priebat. “Each fellow has 2 continuity clinics during the 3 years of fellowship and should fully take ownership of their own clinic patients.”

In addition to increased independence, Dr. Rosinski believes the mentor and mentee relationship is crucial for success in the final year of fellowship. For him, obtaining a post-training position and funding validated the mentor choice he made earlier in fellowship. The right mentor can make or break a fellowship experience. In addition to the everyday focus on establishing a project, the mentor can be the most valuable contact a fellow has in the field.1

One of the difficult decisions a mentor can help with is the choice between a career in academia or private practice. Private practice has the allure of higher monetary benefit, whereas academia provides more opportunity in clinical and translation research.2 In private practice, doctors are more in control of how they work and the patients they see. Those in academia have the benefit of institutionally backed research that helps further knowledge of a specialization. Some suggest the choice is all about personal preference—fellows have spent years diligently working toward this end to choose their path.2,3

Dr. Rosinski always had an interest in academic translational research, specifically bone marrow transplant, and used his fellowship to start carving a research niche. “I knew that I had to establish a project that would obtain funding, at least salary support for myself, starting at the end of my fellowship,” Dr. Rosinski said. The grant writing is overseen by a mentor and must include a compelling story and a detailed, multiyear description of the funding source (eg, young investigator funding, independent funding). “You apply, often times before you have an assay and before you have preliminary data to put into a grant [proposal]. The bridging funding programs for young investigators recognize this and do not expect extensive preliminary data,” said Dr. Rosinski.

Dr. Priebat also pointed to funding as a key challenge for fellows interested in the academic field. Fellows who do not obtain funding in their initial attempt can still build a career in academia. For example, “Promising fellows wishing to conduct research in a lab may obtain 2 or 3 years of funding [from an institution], but the expectation is that grant support will fund it after the initial start-up period.” Dr. Priebat noted that the difficult economic climate has made it harder to get funded for grants and it may cause fellows to shy away from an academic career.3

According to Dr. Priebat, many fellows at the WHC choose to go into practice after completing their fellowship. WHC provides fellows a unique opportunity to work at other institutions in the Washington DC area (eg, the National Institutes of Health and Georgetown University) with an exchange of fellows between the 3 institutions. This allows for cross-fertilization of fellows, with exposure to a broader spectrum of patients across multiple treatment platforms and different styles of patient care.

There also are monthly citywide televideo conferences on coagulation and lymphoma. The advantage lies in seeing how other institutions care for patients, a valuable experience when transitioning into full-time practice. “The challenge going into practice is finding the right practice position,” said Dr. Priebat. “More people are interested in joining a large group as opposed to practicing alone or with one person, since the business side of medicine is becoming very difficult for a single practitioner.” Dr. Priebat stressed to fellows the value of knowing their colleagues and the expertise of the other medical disciplines (eg, pathology, radiology).

“Most fellows coming from large academic institutions get spoiled because of the available expertise not only from their own faculty, but from all the supporting medical disciplines,” he said. “They may find out that the expertise and support are not as good, or not available, and pathology or scans need to be sent for a second review.

The decision during the third year of fellowship to choose private practice or academia can be difficult. Many fellows believe that they are locked into the choice they make until they retire. Dr. Rosinski disagrees, “Most physicians are in private practice or academic medicine because that is where their interests lie. If interests change, switch your path. I know many examples of physicians working in academic medicine who switch to private practice and vice versa.” What starts out as the most appealing option may fall short of expectations and switching paths may be the best option.4

Although fellowship experience is challenging and time consuming, Dr. Rosinski said it has been worthwhile and exciting. “It actually turns out to be a lot of fun as you gain experience, obtain more knowledge, and increase your skills.”

References

     
  1. Melnick, A. Transitioning from fellowship to a physician-scientist career track. Hematology Am Soc Hematol Educ Program. 2008:16-22.
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  3. Kircher S, Feliciano J, Ahmed S. A year-by-year look at a fellowship program. http://www.onclive.com/publications/oncology-fellows/2010/August-2010/A-Year-by-Year-Look-at-a-Fellowship-Program/. Accessed December 27, 2011.
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  5. Horn L, Koehler E, Gilbert J, Johnson DH. Factors associated with the career choices of hematology and medical oncology fellows trained at academic institutions in the United States. J Clin Oncol. 2011;29(29):3932-3938.
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  7. Shanafelt T, Chung H, White H, Lyckholm LJ. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006;24(24):4020-4026.
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