Oncology Fellow Relationships and Challenges

Simon Abi aad, MD

Medicine requires by far the longest "schooling" of any career. By the time we finally become independent practice—eligible physicians, we are already in our mid-30s and have almost never had the opportunity to make an unsupervised decision on a patient’s care plan. The day that comes will be scary for most of us, because we are conditioned to always double-check with the boss, to be under someone’s wing. Suddenly we are the boss, with all the responsibility and liability that come with it. Until that day, we will always have several attending supervisors, some with whom we will work often and others with whom we may not even cross paths.

That’s the part of training no one tells you about: "managing up." I first heard this term during my 2-year career in the pharmaceutical industry, between medical school and residency. It was a mandatory training for new hires. A whole weekend was spent teaching me how to manage the different challenges I would face with the different types of personalities that might end up being my managers. Despite all the evidence- and science-based methods out there, nothing can fully prepare you to work one-on-one with so many people of different personalities and from different cultural and personal backgrounds.

At first, they don’t know you, they don’t trust you, and they almost never believe a word you say. With time, this cold start to your fellowship slowly changes—or not, depending on whom you are working with and the reputation you build. Attendings talk with each other, so expect your performance when working with one of them to be shared with the others. It’s human nature; accept it.

1. Get Your Intel Right

2. Be Ready

3. Observe

4. Render Caesar the Things that are Caesar's

5. Thrive for Independence

6. Remember Why We are all Here

The following is my approach to managing up, based on nothing but my own humble experience.Find out about the person with whom you are about to work. I’m not talking about what they published last month or where they worked before they started at your hospital. Ask how they like to round. What are their pet peeves? Avoid doing that “one thing” certain to anger them early on.The best thing you can do, regardless of whether you are alone or supervised, is to be on top of your game. Know everything about the patient, and I mean everything. Saying “normal” doesn’t cut it (I tried it; doesn’t work)—know the values. Sometimes a small detail of no relevance to you or your plan may be more important to your attending than the disease itself. Always have the numbers ready, regardless of whether you think they matter, and know what other services are involved in care, why they are used, and what they do for the patient. With time, as trust builds, your attending will ask for less information, so you will have more time to focus on the important stuff.This is one of the hardest skills to learn, and I do not believe it can ever be mastered completely. Observe your attending and try to understand their baseline personality, current mood, anxieties (let’s be honest—we all have them), cultural background, and interests. You might have a hard time with a certain type of personality and get along beautifully with another, but at least try to understand how your attending thinks and reacts to a certain situation. Figure out if you are caught in a domino effect: Your attending is under pressure and consequently puts you under pressure. This will help you navigate rough days when you are not on the same page or one of you is not in your usual mood.Most of the time you will agree with your supervisors, but sometimes you won’t. Most of the time they will be right, but sometimes they won’t. Most attendings will listen to you to see where you are going with your thinking, then nicely shut you down with data you never knew existed, because you either don’t know enough yet or didn’t attend ASH or ASCO last weekend. Inevitably, you will meet the attending who is set in the old ways, refusing to accept any suggestion that does not conform to their modus operandi. If it will not make much difference at the end of the day, let it go. I have yet to see any fellow win that battle (the “show me the data” approach almost never works, even if you do show the data). If you believe patient care and well-being are at stake, kindly suggest a tumor board presentation or ask an expert in the field to weigh in.Notice I say “thrive.” Independence in training, as discussed above, is not possible. The next best thing is to get as close to it as possible. How? It took me quite some time to figure this out, but what worked best for me was to study hard to be as good as my attending. I found that this gave me independence of thought and streamlined my life. My presentations became more organized, more focused, and packaged with a solid plan. The results were fascinating: no more endless questioning, triple-checking, and looking at charts together. We simply discussed fine-tuning the plan and moved on to the next patient. Pseudoindependence…close enough. With this approach, you spend time learning the things you cannot find in books instead of having your attending teach you the basics that you didn’t read.One of my chief residents told me once that we, as doctors, are the most compassionate people to our patients but the cruelest people to each other. I guess any physician can understand or relate to that statement. It doesn’t have to be that way; just remind yourself of why you and your attending are rounding on a sunny Sunday afternoon. Remind yourself that you are here to help patients as best you can and learn from each other. We all come from different walks of life and experiences, and it is always fascinating to discover what can be learned from an attending who has been doing this for years, before we even knew what cancer was.

At the end of the day, we need to remember that, as physicians, we all are overworked and strive every day to give our patients the best care in a new healthcare order that seems more concerned about saving money than saving lives. I was blessed to work with great attendings and not-so-great attendings. I learned from all of them, either what to do or not to do. The bottom line: Never take it personally, don’t sweat the small stuff, and remember—it’s temporary!