Planning Ahead for a Career

Dhaval Shah, MD

From the earliest days of medical school, I had a special interest in hematology. This interest became stronger during my residency and culminated in a fellowship in hematology and oncology. The 3 years of my fellowship training were a life-changing experience that will stay with me forever.

I still remember the first day of my fellowship, when I was assigned to the general oncology clinic. The second patient I saw that day had end-stage lung cancer, and we had to discuss end-of-life care with him. I vividly remember the way my attending handled the conversation, which has had a lasting impact on me. Over the next 3 years, I experienced several tough patient interactions, ranging from the explanations I provided at the time of new diagnoses, to discussions on appropriate treatment plans, to end-of-life care discussions. At the same time, I found that the learning curve during these 3 years was the toughest since medical school.

It is a very exciting time to be in the field of hematology and oncology. The treatment paradigm for melanoma that I learned at the start of the fellowship has completely changed over the course of 3 years. As a first-year fellow in training, I found it very difficult to grasp all the information and apply it to patient care. Right from the beginning, it was important for me to focus on my overall career plan, which included identifying areas of interest in which to pursue further research.

I believe that the biggest struggle for many during fellowship is identifying longterm goals. It is important to identify them as early as possible if one is interested in an academic career. This becomes very important toward the end of the first year of fellowship or early on during the second year, to help plan for the remainder of fellowship.

It is also an important time to identify a mentor and a research project in one’s area of interest. It takes time to put together a research proposal, and therefore I cannot emphasize enough the need to start this process early. There is not enough time to complete a substantial research project in the third year alone.

Of course, the structure of the fellowship program varies throughout the country. Some programs emphasize clinical work in the first 18 months and devote the last 18 months to research. Some assign clinical responsibilities to fellows during the first 2 years and allow for a flexible third year devoted either to research or to clinical pursuits. For this reason, it is important for every fellow to identify the structure of their program early in their fellowship. This can help you establish your career goals.

In terms of an academic career, there are 3 different tracks one can pursue: a clinician- educator track, a clinician-investigator track, and a research track. In a clinician-educator track, the emphasis is on education for academic success. If you desire to pursue this track, it is very important to identify the correct academic program based on medical education contributions. A clinician-investigator track, more traditional in oncology, focuses on clinical trials and investigations; regular clinical duties are also included. A research track can involve either translational or basic science research. Translational research is definitely an exciting area in medical oncology, and one that allows for collaboration among those involved in bench research and clinical care. Again, I cannot over-stress the importance of planning for a career path early in your fellowship.

In terms of clinical practice, several variables factor into selecting the right practice. These include geographic location, availability of clinical trials and tumor boards, and the relative advantages of hospitalbased practice versus private practice. The healthcare system is changing, and many private practices are merging with hospital systems. This should influence your decision as well. If you join a private practice, it is important to consider the financial stability of the practice and the possibility of a partnership in the future.

I really enjoy hematology and I had always thought that I would be happy pursuing a career in pure hematology. However, I had very little laboratory experience prior to starting my fellowship. Therefore, right from the start, I knew I wanted to focus on clinical research during my fellowship training. Although I struggled with making clinical decisions during my first year, sometime during the middle of my second year it all began to fall into place, and I started making my own independent decisions. During this time, I was also chosen to be a chief fellow and thus became involved in organizing many teaching conferences for fellows, residents, and medical students.

Following the completion of my fellowship training, I became specifically interested in following either a clinician-educator track or clinical practice. Although I enjoyed the teaching and interaction with house staff in a university hospital setting, as I began interviewing for a position during my third year, I realized that patient care was what I enjoyed the most.

The American Society of Clinical Oncology predicts a shortage of oncologists by the year 2020. No matter what one decides, I think it is an exciting time to be in the field of oncology.