In My Humble Opinion: Advice From a Second-Year Fellow

Utkarsh Acharya, DO

So it’s July 1 and you’ve finally arrived in the big leagues as a freshly minted first year hematologyoncology fellow. After having devoted the last decade to countless hours in medical school and internal medicine training, you have arrived on the final path of your ultimate career destination.

With the promotion to the coveted title of “fellow,” this exciting transition comes with the challenges of navigating through the foreign landscape of the vast field that is hematology-oncology. While it is true that some fellows may have the logistical advantage of resuming their fellowship training at their home residency institution, many of the growing pains that accompany the entry to fellowship are ubiquitous.

Learning To Be A Fellow

Almost within 24 hours of receiving this new title, patients (and even colleagues) will cease to acknowledge you as a board-certified/eligible internist. As they read “Hematology-Oncology” on your newly pressed white coat, they will expect you to address management and prognostic expectations at the level of a proficient oncologist.I recall the excitement and apprehensions that overwhelmed me during my first days as a newly indoctrinated fellow. I have vivid recollections of the constant internal flurry of doubts regarding my ability to grasp my new role and my ability to master the daunting scope of hematologyoncology over the coming years.

Skeptical with concerns about my intellectual reserves and capacity for acquiring new knowledge after 3 arduous years of internal medicine residency, I was naturally distraught over the thought of an impending American Board of Internal Medicine (ABIM) examination, and triaging after-hours oncology pages, imparting prognostic information about life expectancy to highly anxious cancer patients, delineating esoteric side effects of chemotherapeutics I could barely pronounce or barely knew the indication for— oh, and not to mention—learning a whole new specialty. Nevertheless, as the year progressed, the dreaded ABIM boards came and went. Gradually, I was able to maneuver through National Comprehensive Cancer Network (NCCN), chemoregimen.com, and adjuvantonline.com, and I became accustomed to the many common chemotherapeutics we encounter in our daily practice.

Steadily, my apprehensions were allayed and I gradually was able to relay the expected treatment course for my patients and consider contingency treatment plans in anticipation of potential treatment failures for commonly encountered malignancies. I was even able to correctly pronounce many of the numerous tongue-twisting biologics that I used to cringe at the thought of during my early months of fellowship.

I became quite scarce during the many months that I was running the bone marrow transplant (BMT) unit or the inpatient oncology service. Between performing bone marrows, administering intrathecal chemotherapy, transcribing chemotherapy orders, teaching students and residents, and taking care of patients, I could hardly come to grips with where the day went.

Your Role As A Consultant

Given such a hectic clinical workload, it was difficult to carve out dedicated time to read. Fortunately, reassurance from my senior fellows helped alleviate the guilt, as it is evidently a common theme during your first year. With that stated, it is important to find balance between inundating yourself in your new profession and taking time for yourself and family to enjoy your personal life. With time, I realized that this was the natural course of fellowship during the first year, and that over the coming years, I would have plenty of time to consolidate my knowledge and continually grow as an oncologist as so many have before me.Most new fellows have inevitably interacted with consultants from their prior training/hospitalist experience. Unfortunately for some, they became the poor obedient intern who functioned as a human punching bag as an exasperated fellow went on a tirade over their allegedly requesting a “frivolous” consult.

I recall experiencing the apprehensions and frustrations of serving as a junior fellow for a busy consult service in my early days of fellowship. At times, it was vexing to carry the consult pager with its constant never-ending beeping, as it almost invoked post traumatic stress disorder flashbacks of my time as an overnight house officer not so many years before.

The infrequent but intermittent late afternoon lulls would be equally unnerving as I eagerly awaited the urgent 4:45 PM consult for a thrombocytopenia that the patient had experienced for the past 6 months. Many times, it seemed that I could never be accessible enough to my colleagues no matter how early I reported or how late I left.

While some consults may indeed be perceived as “frivolous,” I attempt to utilize every consult request as an opportunity to learn something new and teach a colleague with the hopes of ultimately improving the care of a patient. Invariably, I asked for thorough details regarding the clinical question meriting a consult—the patient’s history, presentation, and clinical course for the requesting physician to ensure that I had the information to provide a quality answer to their clinical question. Additionally, I went through my clinical rationale over the phone and ensured that I was clear on the question being posed.

Surprisingly, this exhaustive process occasionally results in an epiphany for the requesting team and sometimes provides the answer without necessitating a formal consult. The primary premise of going through such details, however, should be to induce thought, educate the requesting resident, and invoke a feeling of thoroughness.

Mentoring During Fellowship

Upon completing a consult, I learned that contacting the primary team to relay the final recommendations over the phone, or in person, not only served as effective communication but also resulted in fewer pages later on (just an added bonus.) I always remind myself that it wasn’t very long ago that I was a resident on the other side of the phone and the decision to consult may not always coincide with the opinion of the individual making the call, so you should attempt to be mindful prior to casting judgment on how “frivolous” the consult may be.Whether your career goals lay in pursuing academics, industry, or private practice, it is especially important to find a mentor that will help coach you as you progress toward your ultimate goals. This is particularly true if you want to pursue an academic-based career. Scholarly performed activities during your training will distinguish you among your colleagues as you apply for eventual high-profile academic positions.

To maximize your opportunities, it may be more beneficial to enter a professional relationship with a seasoned faculty member who practices your tumor type of interest, as opposed to a younger faculty member who is right out of fellowship.

As I Proceed Through My Second Year

One of my biggest struggles during my first year of fellowship was acknowledging the importance of finding a mentor, as it would not be long before I had to apply for a “real” job; and without counsel the options may be far more extensive than you are ready for. Whether it be writing a review together, or becoming involved with a prospective clinical trial, working with the right mentor can serve as a substantial anxiolytic when contemplating your future professional goals.All in all, as I approach the midway mark of my second year of fellowship, I reflect back with fond memories from my first year. While emotionally and physically taxing on a number of occasions, the experience was invaluable and one that instilled humility, patience, and gratitude for the opportunity that I am provided as a budding oncologist. Beyond becoming familiar with the technical aspects of cancer staging, chemotherapeutics, and prognostic indices, my new role has humbled me with the opportunity to engage in many meaningful relationships with my patients and their families during a vulnerable point in their lives.

Utkarsh Acharya, DO is a practicing Hematology—Oncology fellow at the University of Arizona Cancer Center in Tucson, Arizona.