Cancer Topics – Oncology Training – Past, Present, Future Part 2

Getting into oncology requires a lot of education and training. How does one deal with the success and stress of such a journey? In Part Two of this ASCO Education Podcast, moderator Dr. Aakash Desai – fellow at the Mayo Clinic along with guests Dr. Madison Conces – fellow at Cleveland Clinic, and Hematology/Oncology fellowship program directors Dr. Lori J. Rosenstein (Gundersen Health System) and Dr. Deepa Rangachari (Beth Israel Deaconess Medical Center) explore the past, present, and future of Oncology Training. They discuss the transition from training to clinical practice (1:02), how to stay current with new treatments and guidelines (6:39) and what oncology training should look like in the future (12:12).

Resources:

ASCO Education Podcast: Cancer Topics - Burnout in Oncology: Trainee Perspective

ASCO Education Podcast: Cancer Topics – Career Paths in Oncology (Part 1)

ASCO Education Podcast: Cancer Topics – Career Paths in Oncology (Part 2)

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TRANSCRIPT 

Dr. Deepa Rangachari: I think really this idea of what I call work-life negotiation, is present very much during training, and one continues to be very present in your ongoing clinical practice.

Aakash Desai: Hello, everyone, this is Dr. Aakash Desai, I am currently a Hematology and Oncology fellow at Mayo Clinic, in Rochester, and this is part two of our discussion on the past, present, and future of Oncology training.

My guests are, Dr. Madison Conces, Hematology/Oncology fellow at Cleveland Clinic, Dr. Lori Rosenstein, Hematology, and Oncology Fellowship Program Director, at Gundersen Health System, and Dr. Deepa Rangachari, Fellowship Program Director, at Fellowship Program Director, at Beth Israel Deaconess Medical Center.

In part one, we gave our insight into what motivated us to get into Oncology, along with spotlighting the rewards and stresses of going through fellowship.

Today, we're going to look at what the future of Oncology should look like. But first, I and my guests will explore the challenges of transitioning from training to clinical practice in Oncology.

Lori, gives us her answer.

Dr. Lori Rosenstein: You know, I think part of it is, you are in that final stage, this is the rest of your life. So, I think a lot of my fellows feel like when they're leaving fellowship, they have to find the perfect job, because it's where they're going to be for the rest of their life, and I think everybody who is out in practice knows that it's very unlikely you stay in the first job out of fellowship. And so, having less stress on yourself, of finding that perfect experience, I think, finding an experience that fits with your goals and aspirations, and what you see your life being like, is good enough.

And then if you go there, and it turns out it's not a great situation for you, feeling free to go somewhere else, that's a different paradigm than I think fellows expect. They put so much stress on themselves. We're all type-A people, right? And you just want to make the right choice.

 I've now had a couple of jobs. Each of them was the right choice for me at the time, and each of them taught me really important lessons that I have carried on to my next role. When I started my first job out of fellowship, I had no idea medical education was going to be a huge part of my life and career. I like to teach - that was what I knew about myself, but as I got more involved in medical education as a career, as a research opportunity, as probably the most important part of what I do in work, it changed where I was going to go. It changed what I ended up doing. You know, I ended up as a program director, and when I talked to my fellows and I say, you know, my job is research and taking care of patients, and teaching, and then medical education.

To me, medical education is at the top, and that would not have been what I said as I left fellowship. So, having that openness to say, "I'm going to take in experiences and continue to grow and develop," is huge.

Aakash Desai: Madison, what challenges do you think you are going to have to face when you start clinical practice from training?

Dr. Madison Conces: I think for me right now, the main things on my mind are making sure I have the support I need after I graduate. I don't think I'll be abandoned anywhere, but I just want to make sure I join a supportive practice. And I think the second kind of big stress on my mind is doing research as a staff. Obviously, have mentorship, but as a fellow, I feel like there's a little bit more of a structure maybe with that, and so again, I'm not sure how that will be as a staff, but you'll be kind of more of the PI right on the project rather than a co-PI necessarily, and kind of going with patient care, like all the details, and making sure all T’s are crossed and I’s are dotted, and I know I'll be ready when it's time, but I just feel like it's kind of always in the back of my mind, like that it's coming - exciting, and I think one thing I try to reflect on, is I have made it; I'm literally the 10th year of my medical training. If I've made it this far, and I have problem solved, and helped patients, and worked as a team, and been a leader when I needed t0 this far, then I have to have faith that I can figure it out as a staff as well.

Aakash Desai: Deepa, can you answer next?

Dr. Deepa Rangachari: Couple of recurring themes: one, appreciating the interdisciplinary nature of the care that we give, and just recognizing that the need for help, whether it's help with regard to clinical decision making, or intuition, or best practice, or the need for help just in terms of supporting the needs of your patients, those things never, ever go away. That sort of segues very nicely into this idea of consistent and ongoing rapidity of the growth and knowledge that doesn't end when you come out of fellowship. Those things continue to evolve and change well after your fellowship training. You need to know when and how, and who to ask for help. You also need to develop paradigms for lifelong learning. What will it mean to you to be a learner during career span journey, where not only will the knowledge change, but the way in which you access that knowledge will change? And I think those are important things to recognize as challenges of making us transition.

I think really this idea of what I call work-life negotiation is present very much during training, and one continues to be very present in your ongoing clinical practice. And what I mean by work-life negotiation is, on any given day or any given week, or any given month, the way in which you organize these relative priorities at home and at work certainly can change dramatically. And this idea that you can be in charge of refining, and reorganizing, and defining, and turning up or down the dial at home or at work, according to what's going on in your life, is very important to recognize, and so, I think that idea of paying attention to the need to continue to negotiate those factors on a regular basis is something that is very important as you transition from training to clinical practice.

I would not go so far as to say that it necessarily ever becomes easier, but I absolutely think it becomes more manageable for two main reasons; one, you have more control over your career and your life as you move from training to practice, and two-- and I think we should be open and honest about this, you have more resources to do so - whether there's financial resources, or supportive resources. But both of those things, I think, make it more manageable, even if the challenges never go away.

Aakash Desai: And now we'll move on to the next question. I think this is a question I think most fellows have in mind because they realize that as and when they go out to clinical practice, the treatments you learned during fellowship and what ends up happening when you're actually interactive, there's going to be a lot of difference because of all the new updates, and the new drugs, and others that come out. But how do you stay current with new treatments and guidelines, and what would you advise current fellows and future Oncologists, the resources to use for these kinds of updates?

So, Madison, I'll start with you.

Dr. Madison Conces: That's a tough question, I think because some groups, the field is changing so fast. I would say if I'm dealing with something I've not seen before, or I don't know in depth as much as maybe, you know, GI malignancies, which is mostly my interest right now, we'll start out with the NCCN guidelines, and I'm well aware there are plenty of people who don't follow those verbatim and all of that, and there is some interpretation with those, but at least, it gives you a structure to work with. And so, I like to start there, and they usually have at least updated, you know, genetic mutations and some drugs that are, you know, used for those mutations, and so any targeted therapy might be listed on that guidelines. And so, I usually start there and then go beyond there. I mean, I'm obviously talking in a very general sense here, because patients with a really rare cancer, you're just going to have to read up more and look at case reports, you know, see if there's any recent trials. That's kind of where I start, and I just kind of read from there. It's almost like a trickle-down effect in a way.

Dr. Lori Rosenstein: So, Madison, I think that is also where I start - NCCN guidelines, up to date, those sorts of things. I will tell you that as I have gone along, I have become much more likely to phone a friend than I used to be. I used to be, as a fellow, like, "I'm not going to call that person." I still remember, as a fellow, I called somebody at MD Anderson to ask about Mantle Cell lymphoma, and he was absolutely lovely, but I was petrified. I was like, "Oh, he's going to think I'm an idiot, and why am I calling him?"

Now, I know that people are out there and they're experts for a reason, and they're experts because they want to share their expertise, and it's very rare that someone is just completely not interested in helping you. But reaching out, I think there's lots of ways on social media that you can reach out, and my fellows, they think I'm silly because I tell them, "Look what I just found on Twitter." Like, if you're following the right people on Twitter, and people who you trust their opinions, and you know they're experts in their fields, and they say, "Hey, I was just at ESMO, and here's the slide from what I think is really important."

That helps guide me to like, "Hey, this is something." Now, obviously, social media is what it is, and you have to take it with a grain of salt - I try not to trust complete strangers, but at least it leads me to new articles that I wouldn't necessarily have seen. Currently, on my desk, I probably have about 30 "Bloods" because I just am so behind in looking through those, so, knowing that someone who I know in Hematology said, "Hey, this is a really great review article on X, Y, or Z," I'm texting that to my fellows at night when that comes across Twitter.

And likewise, there's some really good groups on Facebook that are specifically for Hem/Onc, that provide support, you know who the experts are, they're willing to help. ASCO and ASH both have ‘phone a friends’ where you can present difficult cases and MedNet -- I have no financial disclosures for any of these, by the way. MedNet is a really interesting ‘phone a friends’ where you can put in a question around a general concept with a clinical case, and get experts in the field to reply back. So, all of those things, I'm much more likely to do now, than I was when I was a fellow, just because I'm now less concerned that people would think I don't know what I'm doing; I'm much more likely to say, "Hey, I don't know what I'm doing, and I need help in this situation."

Aakash Desai: That is so great to hear because social media really has become one of the primary sources of updates that we get. It's definitely not the ideal resource, but I think in a fast-paced world, I think having a few things on updates, I think definitely has been very helpful.

How about you, Deepa? What are your thoughts on this?

Dr. Deepa Rangachari: Yeah, being, staying current, it's really a challenge and I think lifelong learning is often interpreted as sort of like being willing to continue to learn over time. The trickiest thing about this is learning how to adapt the ways in which you learn over time, and so, I'm a very pen-and-paper sort of a person, I've had to really learn how to be savvy with using digital resources. I keep a very brisk PDF library of key literature, not only that I like to read and save to re-review myself, but also in terms of a lot of the teaching, and presentations, and talks, that I'm invited to give.

And so, I think I've gone from a very pen-and-paper modality, and I still have the notebooks that I kept during my residency and fellowship training, and I still remember at the quarter left hand of a page, I wrote something that I really wanted to remember, but I've had to move away from that because I can't be walking around with pen and notebooks all the time. And so, I've developed PDF libraries and things that are available leveraging the technological support provided by my institution to maintain things on the cloud. I've incorporated podcasts into my lengthy commute time to, and from work, to sort of have a chance to keep up. And I think the honest truth is that everybody has to develop a system, and you have to be willing to be flexible and iterative with that system, and modify it, and grow it as time goes along.

So, I don't have any simple equation for this other than a willingness to recognize the importance of being organized, and a willingness to be willing to change as the ways in which we learn and get information change, and a willingness to ask - that's the most important thing, is to be willing to ask others, and have others in your realm, who you know and trust, and can get candid and accurate answers from.

Aakash Desai: So, now I have a very simple question, I think, to which you'll all have to give straightforward answers: What do you think Oncology training should look like in the future?

What are your thoughts, Deepa?

Dr. Deepa Rangachari: I think two of the things that we really have to acknowledge are; one, it has never been possible, nor will it be possible in the future, to think that three years of clinical training can prepare you for all of the questions, and nuances, and advancements that our discipline is fortunate to witness, or that we are fortunate to be a part of, and contribute to. So, really, fellowship training then has to be about developing a very rigorous infrastructure for critical thinking, and lifelong learning, and recognizing general frameworks and scripts for illness, and wellness, and therapeutic intervention, and understanding when are moments to push, and when are moments to sort of take a step back, and sort of revisit or refine the care trajectory along with our patients. I think that's one thing - sort of really just acknowledging there's no way we're going to be able to train people to see everything and know everything, so to really make sure that our training programs provide each trainee, and the program at large, with that sort of rigorous infrastructure and framework for thinking about complex problems, and really for working in complex interdisciplinary teams.

I think the second thing that conceptually, I think, training program leaders should be thinking about is, helping make connections between different disease entities so that we're not training folks to think in disease-specific silos, but really think about emphasizing concepts that are shared across disease entities; thinking about making connections between common disease biologies, and things that may be similar or different, rather than memorizing a series of therapeutic pathways in stage III non-small cell lung cancer versus locally advanced breast cancer, versus early stage pancreatic cancer, but really thinking, what are the things that these different disease entities, at the biological level, or at the care coordination level, what are the things that are similar or different?

I think this serves a couple of different things. From a learning science perspective, it sort of reinforces what we know are effective strategies for knowledge acquisition and retention, but I think also part of our obligation as training program leaders, is to make sure that we're training people to be thought leaders and innovators in their respective clinical and scholarly domains, and that really requires a lot of cross pollination of ideas - what is something that we know works well in lung cancer? How might that same way of thinking or science be applied to a patient in breast cancer? And how could we use those insights to innovate across different diseases? And I think a lot of this comes down to just acknowledging that this finite amount of training time will never be enough to fully expose people to every aspect of the breadth and depth of the discipline, let alone, how we're practicing now, or even thinking about the future. And so, really thinking about making sure that training programs create paradigms of thinking and collaborating, and lifelong learning that will go the distance rather than just emphasizing very specific content.

Aakash Desai: Lori, what are your thoughts on this?

Dr. Lori Rosenstein: From my standpoint, I think if I could totally change fellowship-- the thing that I'm most worried about with my fellows is trying to have all the medical knowledge for Hem and Onc by the time you finish three years. ACGME is so useful, as a program director, to help me guide what I need to be helping my fellows learn during that time. But for any of you who are program directors all know, there continues to be more and more things that we need to show that we're doing - we need to show that we're teaching our fellows multidisciplinary approaches to care of patients, they need to know about patient safety and quality improvement, they need to do research, they need to have all this medical knowledge.

And as more and more things kind of come on the plate of what we need to turn out in three years, and more and more knowledge is out there, it becomes this point where we're not going to be able to do that. And if I had my choice, I would drop the medical knowledge part of knowing every esoteric drug mechanism and pathway, and having testing for that, and more, can we prove that they can critically think and take care of patients who are very complex? It's hard to test on that, and it's hard to just check that box and say, "Complete." But when you're a program director, and you're working very closely with fellows during that three years, you learn that - is this someone you want to take care of your patients or not? And they may be extremely able to take tests and answer questions correctly, and still not the Hem/Onc doctor that we would want them to be. In general, I would just say, less and less emphasis on test taking, and you know, regurgitating medical knowledge, and more and more emphasis on, where can you find the knowledge, and how do you apply it?

Aakash Desai: So, as currently the programs are structured, I think most programs in the country are dual Hem and Onc boarded. Some programs do allow for single boarding, but I guess I want to ask thoughts on the future. There'll be more and more programs who will opt for singular boarding Hem or Onc, rather than a dual board.

Dr. Lori Rosenstein: Yeah, so this is Lori. I think that single boarding is extremely challenging with the way our healthcare structure is laid out. So, you know, we all have to be very realistic that most of our fellows are going to leave fellowship, and are going to practice both Hematology and Oncology, and they're going to take care of the broad spectrum of all of those diseases. And in order to do so, their hospital is going to require they’re credentialed, and certified in both of those. So, I think if we start to either only have Hem, or only have Onc, people are going to have extended training, and it's going to become less and less attractive. It's already a really long slog to be a medical oncologist and hematologist, and making that longer, I really don't think it's the way to go.

Aakash Desai: Madison?

Dr. Madison Conces: I'll jump back to the prior question of where do I see fellowship training in the future. I definitely think that the critical thinking aspect will still be there. I think there'll have to be more of an emphasis on thinking through patient care, and not so much the regurgitation medical knowledge of memorization. I think, you know, core lectures, like I'm sure a lot of fellowships we do here, which I think are really important to have, maybe at the beginning of the year, just to kind of lay out the basics for first-year fellows, but I think beyond that, doing case conferences where it's not crystal clear what even the subject is going to be and walking through it, and making people answer questions even in more of an interactive manner is another way we could go about the conferences.

Other than maybe some very obvious information, I think a lot of this we just need to make sure we know how to find it - like we've already mentioned the NCCN, up to date, I think probably a lot of us got used to doing some of that in residency, in terms of where to find information. We've all been-- I think most people who are in fellowship right now have trained through all their training with computer and the internet, so you know, I think a lot of us are very familiar with it.

Aakash Desai: Yeah, I think completely agree. And I think, you know like Lori mentioned, fellowship should be more than just preparing for Boards. And especially, I think as we move on in our fellowships Madison, and I think I've realized that you know, to know what your blind spots are and when to ask for help is also a critical part of actually training during fellowship. And I think as I come towards the end of my fellowship journey, I think I've realized now that it's a continuation of a longer journey. You know, three years is just the tip of the iceberg, and there's obviously a whole lot of you know, things that I'm going to see in the future. So, that, to me, I think in the future, needs to be kind of emphasized for the fellows to kind of really be okay with the idea of not knowing it all at the end of three years. And as we've geared more towards-- and we talked a little bit about work-life negotiation rather than balance, I think will be also very important.

Thank you. I think those are phenomenal points, and I really appreciate everyone's time today. So, that is all what we have for today. Thank you so much, Dr. Conces, Rangachari, an Dr. Rosenstein, for this candid and vivacious conversation on Oncology training. I'm sure our listeners will appreciate and be able to relate to many of the personal anecdotes that you've shared, and the insights that you have shared today.

Thank you also to our listeners, we appreciate you tuning in to this episode of the ASCO Education podcast.

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