The New Medical Oncology/Palliative Medicine Fellowship Track

I was drawn to medical oncology because it combines science and humanism. I am witness to my patients’ most vulnerable, challenging, and genuine moments. That said, the most lasting memories I have from internship involve the fear, shock, and failure that I felt as I cared for ill or dying oncology inpatients. I decided that if I was to become a medical oncologist and be entrusted to care for patients with a life-threatening illness, it was my responsibility to be as well trained as possible in physical symptom management, communication, and nonphysical distress. I would follow them from diagnosis to either cure or death and never abandon them. Training in palliative medicine as well as medical oncology felt like honoring the saying: “To cure sometimes, to relieve often, to comfort always.”

I am just finishing up a 2-year medical oncology fellowship after completing a hospice and palliative medicine fellowship and will be starting as an attending in both GI oncology and palliative medicine this summer. This dual training is becoming a much more frequent occurrence with medical oncologists,¹ and some oncology training programs across the country have integrated medical oncology/palliative medicine into a 3-year ACGME-accredited fellowship similar to hematology/oncology. This article aims to recount my experience in this dual training, including the challenges I faced and the benefits I reaped. Hopefully, this will help better inform oncology fellows regarding whether or not this training suits them.

Benefits

I will never forget visiting a hospice patient as a palliative medicine fellow and talking with his wife. She felt their oncologist was wonderful, knowledgeable, and connected with them, but he had abandoned them since hospice enrollment. He didn’t call and was no longer involved in decision making. And believe me, there were decisions to be made. Should they continue tube feeds? What were the benefits and risks? What should they do about his secretions that were severely impacting his quality of life? When and how should they tell other family members? Most likely the oncologist “abandoned” his patient because he just didn’t know or have experience in caring for patients while they were dying. Just as I can advise the right chemotherapy regimen for treating metastatic cancer, I can also assure symptoms are managed right up until death or assure a patient is sedated if all other conventional methods fail.

This continuity of care is vital to helping patients transition as their cancer progresses. I have known them for months to years and have learned and elicited their values and goals throughout their course of cancer. They trust me because I know them intimately, what they have been through, and have fought beside them during their battle with cancer. Therefore, when I tell them we have come to a point where their life would be “better” (based on their own definition) without further chemotherapy, they believe me. They can accept their fate and begin to find other sources of hope to sustain them for the time they have left.

As oncologists, we gather to discuss challenging clinical quandaries in conferences, but we do not discuss how emotionally draining it is to care for certain patients or families and grieve their loss. In hospice and palliative care, emotional coping and strategizing is a crucial piece of the multidisciplinary meeting time with chaplains, social workers, psychologists, nurses, and physicians. Oncologists are prone to burnout² and having the experience of a true multidisciplinary support network in cancer care and learning emotional resilience³, such as that learned in hospice and palliative medicine, can help improve job satisfaction and prevent this burnout.

Solid malignancy services can be heavily burdened with patients who have suffered complications from chemotherapy or their cancer. A palliative medicine training can assure that I can always make an impact on the patient’s care and on the residents’ and fellows’ education whether I am titrating medications to relieve refractory nausea or pain, navigating tricky goals of care issues with challenging families or young patients, or helping coworkers and residents grieve their dying patients.

Lastly, improved end-of-life care, including decreased spending and better symptom management, are hot button topics. In an era when research money is tight and innovation is valued, having insight into strategies that could reduce aggressive care at the end of life while respecting patients’ values and goals could allow for a successful, independently funded research niche.

Challenges

One potential issue is the worry that oncologists trained in palliative medicine may not be as aggressive and would encourage patients to seek comfort care despite there being further therapy available. Interestingly, after my palliative care training, a mentor has joked that I am far more aggressive in some situations than she would be. For example, after getting a sense of the value a patient places on quality of life and extension of life, I explain how potential therapies may impact each of these points. If a patient chooses an aggressive therapy in order to reach a goal that I think is possibly achievable despite significant potential toxicity, then I will likely treat. It is one thing to treat aggressively as a rule and another to tailor your aggressive therapy based on a patient’s prognosis, values, and goals.

A second challenge is whether a physician can wear both an “oncologist hat” as well as a “palliative medicine hat.” The answer varies depending on the situation. Many of my oncology patients are thrilled that I am trained in palliative medicine because they feel assured that no matter what happens with their cancer, they will not be left to suffer and will have guidance if they have to face the dying process. On the other hand, patients who view palliative medicine as equivalent to hospice may not trust me to make aggressive decisions for them. In addition, I need another practitioner to “share the load” when caring for patients who have extreme and/or refractory symptoms.

Lastly, I had not anticipated just how difficult it would be for me to watch a patient progress from diagnosis to death. A 50-year-old man with metastatic pancreatic cancer was admitted to the inpatient hospice unit for pain and delirium management 8-9 months after I had met him, a healthy-looking man. It had been a few months since I had last seen him, but when I walked into his hospital room I had to leave and check that I had entered the right room. He was no more than skin and bones. I felt like a proxy family member watching from beginning to end as the cancer consumed him. In that moment I realized, at least in part, why medical oncologists may not be fully present during a patient’s death… it is very, very hard to bear witness to. I feel lucky that I have been formally palliative medicine-trained, so those emotions don’t keep me from being there for my patients and their families at the end.

On a practical note, a hospice and palliative medicine fellowship after oncology training will break up your oncology experience by a year and may make restarting this oncology career more challenging. This must be weighed against the depth this training adds to your experience.

Conclusions

Medical oncology is a complex field, rich in basic science, mechanism of actions, and cutting-edge clinical investigation but also physical, emotional, social, and existential distress for the patient. The field of hospice and palliative medicine is well suited for training oncologists in the science of compassion and communication, which can significantly improve the experience of cancer patients. A push for some palliative medicine training in all oncology fellowships would be extremely appropriate, but for individuals who feel this aspect of oncologic care is what gives them job satisfaction and is an essential part of their practice, I would strongly recommend a year-long ACGME accredited hospice and palliative medicine fellowship. I sleep well at night.

This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.