Every year, come July 1, first-year hematology/oncology fellows embark on their last phase of training. Although their backgrounds and career goals may differ widely, all of them will face the daunting learning curve and emotional demands inherent in caring for people with cancer.1

Possibly the biggest challenge to first-year fellows in hematology/oncology is the sheer breadth and depth of knowledge they need to acquire, explained Ann LaCasce, MD, director of the Dana-Farber Cancer Institute (DFCI)/Partners Cancer Care fellowship in hematology and oncology. “With the explosion of molecular techniques and identifying targets, there is an enormous amount of information to assimilate,” she said.

The DFCI/Partners Cancer Care hematology/oncology fellowship has fellows care for patients as their own instead of following an attending’s patients. “I think the most powerful way to learn about a disease is to take care of a patient with that disease, reading about what relates to their pathophysiology, treatments, and complications.” The fellowship program also has a number of conferences directed at fellows, from introductory seminars to disease-specific conferences. “I think you learn a lot when you present a patient to colleagues or to a group of attendings,” Dr. LaCasce said.

Kerry Lynn Massman, MD, a first-year fellow in that program, understood early on that learning what she needed to know would take a lot of self-discipline, as well as patience. “The major challenge initially was coping with my lack of knowledge,” she said. “I went from being a competent, confident senior resident, to suddenly finding myself in disease centers where I didn’t know the third line of chemotherapy. Sometimes I didn’t even know the first line.”

Dr. Massman finds some comfort in looking at upper-level fellows and trusting that knowledge will come to her as it did to them. But she also has taken a practical, systematic approach to furthering her understanding of cancer and caring for patients who have the disease. “I’ve been trying to focus on one cancer a week,” she said. “I’ll read in depth on the prognosis, the staging, the treatment, all the new therapies, and reformat that information into a teaching sheet so that I can refer back to it in the future.”

Dr. LaCasce recommends that fellows tap individual attendings for recommendations on the best literature sources for a particular situation, and that they take the lead in interacting with patients under their care. “Try to be the person conveying information to that patient,” she said.

In addition to acquiring vast amounts of knowledge, first-year fellows also must learn to cope with the emotional burden of taking care of patients who may not survive. “You form tight relationships with patients who have been diagnosed with life-threatening conditions,” Dr. LaCasce said. “Trying to navigate families and communicate about prognosis and transitioning care from aggressive treatment to palliative care is extremely challenging.”

These tasks are difficult even for senior physicians, and can be especially daunting for those just starting as a patient’s primary caregiver. Dr. LaCasce recommends speaking and sharing with other fellows and attendings. “Talk to the people you’ve shared those patients with. When somebody dies, or something terrible happens, you really need to stop and talk to people and process it a bit instead of ignoring it and moving on,” she said.

Along with the challenges, the first year of a hematology/oncology fellowship includes important milestones. “You learn how to write chemotherapy orders, how to explain to patients what they are going to be treated with, what the goals of care are, and to talk about the toxicities of chemotherapy without completely unnerving patients,” Dr. La Casce said. Fellows also learn in their first year how to discuss a disease and prognosis with a patient, and how to approach an end-of-life discussion.

Some milestones, however, are cause for celebration. For Dr. Massman, an important first was the day a patient of hers completed chemotherapy and radiation. The patient had a complicated medical history and difficult-to-manage side effects, and had several hospital admissions and visits to the infusion center. “It brought me a lot of joy to have that treatment course finished,” she said. “She had a highly curable cancer, so she should live many cancer-free years.”

Another important first for Dr. Massman was surviving her first overnight call. “I feel much more comfortable now, having figured out my way around the hospital, and how to orchestrate acute issues in a new environment,” she said.

Dr. Massman’s overall goal in her first year is to learn how to take good clinical care of patients by deepening her clinical knowledge and developing a procedural skill set. “We have to learn a whole different set of skills outside of residency and be comfortable with both,” she said. At the same time, she is using this first year to reflect on her course and picture herself achieving a successful career in academic medicine. To aid her in this endeavor, she is turning to mentors. “Mentorship is really rich in this institution,” she said, noting that she has set up reminders in Outlook to meet with someone every month. “I’m trying to get a sense of what my career might be, look into the future, all in this first year of trying to figure out the clinical side of oncology.”

Stay tuned for “Spotlight on Second-Year Fellows” in the next issue of Oncology Fellow Advisor.

Reference

     
  1. 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 October 21, 2011.
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