For many fellows, training to be an oncologist has been a trial by fire, especially when it comes to interpersonal issues in the hospital. Young oncologists often find themselves looking to senior faculty members while navigating the ins and outs of the hospital system, gaining the trust of patients and their families, and overcoming conflicts that arise. One group in Texas has developed an evidence-based model using a Socratic approach to fill this gap in training.

Psychologist Ernest Frugé, PhD, and his colleagues are training pediatric hematology–oncology fellows at Texas Children’s Hospital in Houston in the art of leadership and reflection. That is, they are teaching fellows how to analyze the thinking, emotion, motivation, and social context of themselves and others to manage complicated professional situations and relationships.

The group trains fellows to apply the same disciplined reasoning approach they use to think through complicated biological phenomena to the psychological, social, and institutional dimensions of their work, said Dr. Frugé, associate professor in the Department of Pediatrics’ Section of Hematology–Oncology at Baylor College of Medicine in Houston and director of psychosocial programs at Texas Children’s Cancer and Hematology Centers. “Being able to figure out how to get the best out of the ensemble of professionals around you, to serve the best interest of the patient, to advance science, or to get the best educational approach possible requires effectively working with and leading people in groups.”

The Reflective Practice and Leadership seminars have been offered at Texas Children’s Cancer and Hematology Centers for more than 15 years. Currently, it is mandatory for first-year fellows to attend the confidential seminars for 90 minutes every 2 weeks. Dr. Frugé and 3 or 4 other faculty members lead groups of about 12 fellows in each session. In surveys collected over the past 6 years, participating fellows reported a significant improvement in their ability to manage a multitude of complicated psychosocial factors involved in their relationships with patients and the medical team.1 When the seminar is no longer mandatory, 75% of fellows choose to continue attending it, Dr. Frugé said.

In the sessions, fellows are encouraged to bring up difficult clinical, educational, research, or administrative issues that they have encountered. These are not, however, therapeutic sessions to help fellows cope with the emotional burdens of specializing in oncology. “While it certainly is available for people who have personal issues or want to deal with emotional reactions to those issues, it’s really a minority of what gets discussed,” said Carl Allen, MD, PhD, assistant professor in the Department of Pediatrics’ Section of Hematology–Oncology at Baylor. “It’s really more thinking about academic medicine and oncology or the team that you’re working in as a system and then how you can optimize your functioning within that system.” For instance, Dr. Frugé said potential topics could be how to get the nursing service to deliver medications on time when there is a staffing shortage or how to work with a family to help them better understand the risks and benefits of choosing an alternative treatment.

Dr. Allen began attending the seminars as a first-year fellow at Texas Children’s, continued with the program voluntarily afterward, and now serves as one of the faculty members who guide each session. “I thought it was a useful forum both for specific issues that I had and for hearing other people’s challenges. It’s a place where people can take an observation, validate it as a pattern, identify what to do to improve it, and then think through the next steps. It’s almost like a thought laboratory where you can think things through and come up with a well-developed package to present to leadership when you’re trying to recommend systematic changes.”

The reflective practice sessions involve 6 main steps (Table).1

Table. Steps for Reflective Practice
1. Distill each difficult situation presented into a question that represents a leadership challenge for the physician;
2. “Reflect” on and outline what the circumstances are and all the factors involved;
3. Formulate a working hypothesis to describe what may be generating or maintaining the problem;
4. Develop a plan of action by considering the feasibility and consequences of different options;
5. Summarize the “diagnosis and plan”; and
6. Review how the session itself went and if there are any general learning points on leadership that should be highlighted.
Adapted from reference 1.

Although it may sound like mentoring, the faculty who lead these seminars generally avoid providing their own assessments or advice. The goal is to help fellows develop the ability to effectively and independently reason through complicated psychosocial scenarios. As such, reflective practice is best taught like everything else in graduate medical education, Dr. Frugé said—case-based and in a group format with experienced physicians guiding junior colleagues in thinking through difficult situations. To establish a similar program elsewhere, it would be important to have the full support of the department’s leadership so fellows are given protected time to attend; the participation of experienced and well-respected faculty; and consistent use of the 6-step method, he added.

“We just want our fellows to have an opportunity to apply that same discipline [that they use to reason through biological problems] to these other dimensions of their role until it becomes a habit, it gets in their bones so to speak,” Dr. Frugé said.

A comprehensive description of the program, sample sessions, and alternative formats for the seminar are available at



  1. Frugé E, Mahoney DH, Poplack DG, Horowitz ME. Leadership: “They never taught me this in medical school.” J Pediatr Hematol Oncol. 2010;32(4):304-308.

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