Staying Afloat When the Floodgates Open

Aju Mathew, MD, MPhil

It is quite easy to be drowned in the rising floodwaters of hematology and medical oncology, especially when you start training. As a recent graduate, I barely managed to keep my head above the water level. When I joined the hematology and oncology fellowship program at the University of Pittsburgh, I only had a faint awareness of the storm that was going to hit me—in spite of the fact that I had completed my residency training at the same institution and spent numerous rotations in the inpatient unit and ambulatory oncology clinics. I had thought that decision making in oncology seemed quite straightforward and that all I would need to do was follow the guidelines. However, that was not the case. Each patient’s cancer story was unique and the decision making had to be individualized, taking several factors into account, including an understanding of the patient’s state of health, standard-of-care treatment options, recent research, and, more importantly, patient preference.

How can an oncology fellow tackle the steep learning curve in the field? One of my mentors gave me very valuable advice early on—that I could follow a patient’s prior oncologic management history and learn how he or she was managed at various points of stable or progressive disease or during complications of therapy. By asking how you would treat that patient today, given the same presentation, you can help to identify current controversies in cancer care.

Let me illustrate this with an example. You are seeing a patient with metastatic breast cancer. Her prior history reveals that she was treated with anthracycline-based chemotherapy for stage II hormone receptor—positive cancer. Knowing this information, you could ask yourself how you would treat her now, if she presented similarly. Such a line of thought would bring forth several learning points—for instance, you could consider the use of 21-gene assay, the possibility of using a non-anthracycline–based treatment regimen, or even omitting chemotherapy altogether. Use each patient encounter as a learning opportunity.

For your continuity clinic, try to be prepared ahead of the clinic visit by staying up-todate on new data. It is quite easy to fall back on the commonly used National Comprehensive Cancer Network guidelines. You may certainly use guidelines such as these for reference, but, always refer back to the primary source of evidence. The guidelines may not give you the details you may need. For instance, to decide between docetaxel and paclitaxel for a woman with early-stage breast cancer, you may need to refer to the seminal research article to understand the differences in efficacy and side effects between the 2 options.

Soon, you will start getting swamped with a variety of medical journals. To help manage all of the reading material, select just a couple of journals to read regularly. A more efficient way to study is to ask your faculty for “must read” articles, in order to understand advances in the field.

Always remember that the ideal material is usually within the hard covers of a textbook or the pages of a well-written review article.

Your supervising faculty has a wealth of experience. Learning from faculty members is often just as important as self-study. Watch them interact with patients and discuss the results of imaging studies. Chart treatment plans with them. More importantly, ask them the rationale for their management decision. You will discover the value of experience in patient care, especially when you encounter the “zebras” in oncology. Establish good relationships with the faculty with whom you interact over the 3-year span of your fellowship. You will need their support in the future, regardless of your career choice.

In addition to working closely with, and learning from, faculty members, consider how your colleagues may also contribute to your learning, especially in their own areas of interest and expertise. You may be surprised to see how much you can learn and how you can instruct others through the process of collaboration. Discussing a case history or topic as a group, either as part of case conference or in an informal setting, is extremely beneficial to you and your patients.

Finally, always be professional in your manners and be respectful toward others, including nurses, nurse practitioners, physician assistants, and trainees in other specialties. Most of them will have a wealth of experience in the practicalities of patient care. The gospel truth of “do to others as you would have them do to you” is something to keep in mind throughout training and your career.

I am sure that, at times, you will find the fellowship experience bewildering, but it is worth every dime. Remember, your future patients deserve the best. You owe the next 3 years of your training to them.