What I Have Learned Since Fellowship: Tips for Professional Success and Happiness

I have just finished my 15th year on faculty and my 13th year directing the hematology/oncology fellowship program at the Medical University of South Carolina. Although none of what I have learned along the way is truly novel, I hope that a few observations born of experience in my professional life will help you achieve success and happiness in yours.

Board Exams

Take ’em, Take ’em Early, and Keep On Taking ’em Until You Pass ’em

Take whatever boards you are eligible for as early as possible. A board exam covers the specialty’s full breadth, yet odds are good that once in practice you will quickly come to focus in some subset of the specialty. Do not be surprised if you quickly lose much of your knowledge, skills, and currency in any area in which you do not regularly practice. So take your exams at the earliest opportunity. For those training in combined hematology/oncology, do not wait to take the hematology exam until the year after taking the oncology exam. And if you feel you need extra study time, ask for it (ideally when negotiating your employment arrangements). Your employer wants you to obtain and maintain certification for all boards for which you are eligible, so a wise employer should grant you a reasonable amount of study time if you think you need it.

Experience Always Trumps Reading, but if Reading Is All You Can Do…

Unless you are convinced your knowledge in a particular area is deficient, do not bother studying much for your first attempt at the boards, with 1 exception: hematology/ oncology fellows should not forget that gynecologic oncology is on the oncology boards. In many adult medical oncology and hematology/oncology programs there is little opportunity to attend didactics in—let alone practice— gynecologic oncology, so this area of the boards can hurt you if you have not even read in this area. Remember that board questions are written carefully, and it has been my consistent observation across multiple exams that if you have seen a case of X within the last year or so, you will quickly know the right answer. Conversely, if you have never seen a case of X, you may be able to narrow it down to a couple of choices, but mere preparatory reading likely will not help you any more than a coin fl ip would. So if you fail an exam, actively seek opportunities to practice (and read) more in the areas in which you were deficient. (You will always learn far more from practice with reading than reading without practice.) Then take that exam again as soon as possible.

"The best advice I can give you is to know yourself and then do what makes you happy."

Do Not Waste a Year of Your Life

If you are in a combined adult hematology/oncology program and facing the prospect of not 1 but 2 (expensive) exams, just suck it up and take them both until you pass them both. It is silly to have spent an unrecoverable year of your life in exchange for a modest fellow’s salary and the right to take the hematology boards—and then end up not getting certified in hematology. (At that rate, you would have been far better off doing just 2 years of oncology training and going right out into practice.) So take ’em both until you pass ’em both. It makes an important statement to yourself, your colleagues, your institution, and, most importantly, your patients. And if you flunk the hematology boards on your first attempt but then are so focused on your oncology practice that you realize you need to take a hematology review course prior to retaking the hematology boards, then by all means take a hematology review course.

Your Next Board Exam Is Sooner Than You Think

Maintenance of certification (MoC) processes are far from perfect, but they are the best methods we have for assuring those around us of our continuing competency. You should keep abreast of the seemingly ever-changing MoC requirements and develop a plan to meet the requirements starting at the earliest possible point. Your practice and perhaps other work will quickly grow to consume your professional life, so if you have not developed and followed your MoC plan, you will find it needlessly challenging and anxiety-provoking to rush at the end to finish everything that must be done before you can once again sit for the boards.

Career Direction

Don’t Worry, Be Happy

Barring the grossest lapses of competence and professionalism on your part, you will always be highly employable— likely in the setting of your choice, too. Furthermore, as you age, you’ll increasingly appreciate how short life is, particularly the truly healthy portion. Therefore, the best advice I can give you is to know yourself and then, whenever possible, do what makes you happy. And, if your interests change in time—especially if you reach a point where, day after unending day, you get up in the morning not looking forward to what awaits you—be willing to change your work.

Loans? My Happiness Doesn’t Need No Stinking Loans

When you finish fellowship and enter practice, you will quickly earn enough to provide you and your family a good quality of life and still be able to pay back your student loans far faster than you might be able to believe right now. Therefore, I recommend you try to not let the size of your loan portfolio drive your choice of initial job. Select the position you feel you will enjoy the most rather than the one that will compensate you the most.

Making the Transition

I’m Really in Charge Now?

As recently discussed by William Wood,^1,2 a regular contributor to HemOnc Today, the initial post-training stage of your professional life may be the most unnerving you will ever face, quite unlike the beginning of your internship or fellowship.

Late in fellowship you will be pretty comfortable in your work due more to a growing base of experience than a growing base of knowledge. But another invisible factor contributes substantially to your comfort in training: you still are not responsible for what happens to your patients, at least not nearly to the extent that your faculty are. But as noted by Dr. Wood, suddenly one morning—and for the rest of your career—no one is more responsible for the consequences of your actions than you.

My recommendation: do not worry so much about being smart, and instead just be willing to work hard—and be humble. Quietly do what you are confident in doing, but when you realize you know less than would best serve the situation, admit it and seek help. Tell the patient you need time to review the latest literature. Step outside the exam room and ask your colleagues for advice. Present the case at tumor board. If there is not a tumor board where you practice, start one. Your peers and patients will be more impressed with you for your self-recognition of your deficiencies and your quest for self-improvement.

A Few Points for Success in Practice

The Toughest Decision: Doing Nothing

Advancements in medical science and in the evolving medicolegal and healthcare financing landscapes have created an often inappropriate sense of obligation, even a terrible temptation, to do things to patients. Early in your career, when your experience base is still relatively light, there can be insufficient appreciation of the potential for harm—medical, financial, and otherwise—posed by many interventions, both diagnostic and therapeutic. In 2011 cancer remains a bad disease, and though a majority now survive their disease,³ about a third still do not. Therefore, “first, do no harm” remains a terrific guiding principle.

"It fundamentally remains your choice in every encounter how much you will succumb to the ever-present pressures to minimize your time with the patient."

Patient History: The Hematologist’s Best Friend

Typically, different types of satisfaction are gained from addressing oncologic problems versus hematologic problems. In malignancy (solid or liquid), the diagnosis is rarely in question. (Do not be misled by the disproportionate share of unusual cases of diagnostic question that funnel into an academic center.) Thus, your satisfaction as an oncologist is largely derived from (1) identifying which treatment likely will off er the greatest benefit/cost ratio and (2) using your knowledge and skills to guide the patient through the treatment as effectively and comfortably as possible. After that, aside from further surveillance and prevention efforts, there is not much more for you to do than what your patient has been doing all along: hope for the best.

In nonmalignant hematology, though, the diagnosis is often the primary question. Toward that end, I will opine that the diagnostic hematologist’s best friend is almost always the patient’s history. Th e modern pressures impeding the physician’s ability to take a full history are apparent, but you will have a pretty good idea by the end of the evaluation what the correct diagnosis is if you (1) take a complete history and (2) always give preference to diagnoses that unify as many of the case findings as possible. Th e quickest route to erroneous diagnosis, futile (even harmful) diagnostic and therapeutic interventions, and dissatisfaction of all parties is skimping on history-taking and focusing exclusively on the patient’s hematologic issue.

Most nonmalignant hematologic aberrancies are reactive, not primary. Make a point of figuring out the true root of the problem if you want the best outcomes. If you cannot figure it out at first (for lack of time or whatever other reason), do not give up. Revisit the situation soon and again think about the best unifying diagnosis. And if a few at-bats still do not yield the right answer, be humble and ask for help. Truly new, never-before-seen diseases are extremely rare, so it is far more likely that the situation indeed is diagnosable and just needs a fresh look—and the persistent use of readily available knowledge sources.

Normal Is Not Always Normal and Abnormal Is Not Always Abnormal

Look at every test result (there is a reason that a complete blood count includes more than just hemoglobin, leukocyte, and platelet counts) and try to at least briefly ignore the presence or absence of the High/Low flags, asking instead whether the result is Expected/Unexpected. (Oh, for a computer that could show “E/U” instead of “H/L”!) For example, try to train yourself not to reflexively think—let alone reflexively work up or treat—“iron deficiency” upon seeing microcytosis. Take a moment to trend the parameter and put it in context. For example, chronic stable mild microcytosis in a black person is far more likely to be alpha thalassemia than iron deficiency. Conversely, a newly “normal” mean corpuscular volume in a known thalassemic may bear as much significance as frank macrocytosis in a nonthalassemic.

What Patients Really Want From Their Physicians

Sure, your patients would like you to cure them, but they understand this often is not possible, so what they want even more is for you to allay as much as possible their physical pain and then the psychological pain that comes from the uncertainty about their future (and their family’s future) that is inherent with any serious illness.

Allaying a patient’s uncertainty takes a physician’s time; there is just no way around it. But it fundamentally remains your choice in every encounter how much you will succumb to the ever-present pressures to minimize your time with the patient. Furthermore, though you may enjoy the artifice of duty hour limits while in training, once in practice you should never forget that in becoming a physician, you chose to always place your patients’ interests before yours, so always try to give your patients whatever time of yours they need. As a rule to live by, “do unto others as you would have them do unto you” will not be going out of style anytime soon.

Final Words

Odds are you will be competent upon finishing your training, but competence is merely necessary, not sufficient, for happiness. If you got into medicine for the reason most of us did, every day you spend serving your patients and colleagues the best you can will go a long way toward furthering your own happiness. Good luck!

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

References

1. Wood W. Fellows’ perspectives: looking back: lessons learned in fellowship. HemOnc Today. May 25, 2010. Available at HemOnc Today. Accessed August 15, 2010.
2. Wood W. In practice: getting started as an attending. HemOnc Today. July 25, 2010. Available at HemOnc Today. Accessed August 15, 2010.
3. American Cancer Society. Cancer Facts & Figures 2010. Atlanta: American Cancer Society; 2010.