If you are anything like me, you are sitting on the couch staring at your laptop with Disney Junior on the television and a rambunctious toddler running from his room to the couch banging on a tambourine. You know that you have an article to write, or a chapter in your ASCO-SEP to read, but you realize that these will probably have to wait until you get back to work on Monday. Unfortunately, if you are similar to me, you are also the proud owner of an ever-increasing collection of student debt. You likely have an array of different types of debt (unsubsidized, subsidized, private, consolidated), each processed by a different company, and these debts may even be transferred to other companies yearly just to complicate things. Additionally, you have probably felt a certain amount of guilt about possessing debt. However, despite the difficulties of managing and dealing with debt, there is hope.

My particularly large amount of debt has accrued through a series of events. First, I attended a private medical college. Second, I did so in the Northeast, where everything costs more, including tuition, rent, utilities, food, and other day-to-day items. With little outside financial support, and a wife in law school, I first had to take out private loans, then Grad PLUS loans, in order to have enough money for living expenses.

Once I completed medical school and started my residency, I quickly realized that living in Manhattan on an intern’s salary did not leave me a lot of income to put toward repaying my debt. To avoid making payments, I put my student loans into forbearance, meaning that I could avoid paying any interest or fees. The downside was that interest would continue to accrue and compound. Near the end of my second year, my daughter was born. This meant that we needed a nanny and a bigger apartment— and there was absolutely no way I could begin to pay off my debt.

After completing a year as chief resident, I started fellowship. Shortly thereafter, my son was born. Fellowship in Boston again meant a high cost of living (now with 2 children), with only a nominal increase in salary. I continued to put my loans into forbearance and primarily focused on providing supplemental income to pay for the rising costs associated with child rearing. Although it is still demanding, fellowship offers more elective time, particularly in the second and third years. I began moonlighting at the Boston Veterans Administration (VA) in the emergency department midway through my second year of fellowship. At this point, I had finished the majority of my inpatient rotations and had fewer weekend calls and tumor board presentations than I had during my first year of fellowship. By working two, 9-hour shifts per month at the VA, I was able to increase my income by roughly 25%. Additionally, modest honoraria provided for writing magazine articles helped fill the gaps from time to time.

As I started to look forward to my career as an oncologist, I was confronted by how I would repay my student debt, yet still provide for a comfortable lifestyle for my family. Initially, I planned to go into private practice, which was primarily a financial decision since my passion was for academic medicine. As my fellowship progressed, I realized that I did not want to hedge on my career goals. I decided that I would pursue academic malignant hematology and, if need be, make other concessions in order to achieve this endpoint.

First, I knew I would have to relocate. According to the 2016 version of the Medscape Oncologist Compensation Report,

 the Northeast has the lowest compensation rates compared with the rest of the country. Additionally, the cost of living is greater in the Northeast than in most other regions, particularly if you live near one of the larger cities. Consequently, and after a great deal of research, I accepted a position at the University of North Carolina at Chapel Hill. This allowed me to pursue my interest in academic malignant hematology while living in a lower-cost region with improved physician compensation. Importantly, if you are interested in buying a home, you should be aware that many banks offer a Physician Mortgage Loan, which has the benefit of giving physicians with extensive debt and limited funds the opportunity to obtain a mortgage with 100% financing and favorable terms. Pursuing this type of mortgage has allowed me to purchase my first home with relatively little money in my savings account. Most banks also require a very good credit score, so you should ensure that you pay your credit card bills promptly and maintain a reasonable balance throughout training.

Second, I had to address my debt directly. Since my income:debt ratio was not favorable, I looked into income-based repayment. The first, and most important, website I reviewed was the Federal Student Aid website, which is administered by the US Department of Education (

www.studentloans.gov/myDirectLoan/ index.action#

). They offer several repayment plans with payments that are calculated based on income; if you qualify for these plans, they can substantially decrease your monthly payments. This allows you to pay down your debt slowly and still maintain a comfortable lifestyle. The interest rate is generally favorable, so it would be prudent to pay off nongovernment debt (private loans, credit cards) more aggressively. It should also be noted that federal government loans are forgiven after 20 or 25 years of regular payments (depending on the payment plan),

 so choosing to pay down your federal student debt slowly will not necessarily mean you will pay more in the long run.

Additionally, the fact that 12 of my 13 loans can be consolidated into one monthly payment makes this a convenient option.

Finally, if you are interested in either basic or clinical research, you should be aware of the Loan Repayment Programs offered by the National Institutes of Health (NIH) (

www.lrp.nih.gov/eligibilityprograms# programs

). These programs are aimed at decreasing the loan burden of physicians who choose to pursue a research career.

 If you apply and are accepted, you can have up to $35,000 of your qualified educational debt paid annually by the NIH. For new physicians who are concerned that a career in academics is associated with lower compensation, this may help offset some of the financial burden of a lower- paying position.

If you are anything like me, despite working incredibly hard, not getting paid adequately for many years, and accumulating an incredible amount of debt, you could not imagine any other career. You should remember to pursue your exact medical career goals and not allow your finances and debt to dictate your level of happiness. By taking certain measures (see Sidebar), you can have a great job, spend time with your family, and live comfortably, despite having substantial student debt.

Peckham C. Medscape oncologist compensation report 2016. Medscape website. www.medscape.com/features/slideshow/compensation/ 2016/. Published April 1, 2016. Accessed August 1, 2016.

Federal student aid website. https://studentloans.gov/myDirect- Loan/index.action#. Accessed August 1, 2016.

Eligibility & programs. National Institutes of Health Division of Loan Repayment website. www.lrp.nih.gov/eligibility-programs#programs. Accessed August 1, 2016.

Articles

If you are anything like me, despite working incredibly hard, not getting paid adequately for many years, and accumulating an incredible amount of debt, you could not imagine any other career.

How to Survive With Limited Finances (and a Family) as a Hematology-Oncology Fellow

Sharon was a 40-year-old female patient, and she did not want chemotherapy. As a first-year hematology-oncology fellow, it was my job to convince her otherwise. Sharon was initially diagnosed with early stage, estrogenreceptor— positive breast cancer 2 years before my first visit with her. At that time, she was advised to have surgery, as well as hormonal therapy and, possibly, chemotherapy. Surprisingly, Sharon refused surgery and all adjuvant treatment. After multiple failed attempts to convince her otherwise, she agreed to be followed very closely by her medical team with breast exams and mammograms. As expected, her cancer progressed. She was ultimately diagnosed with stage 3A breast cancer several months prior to my initial evaluation.

	As I sat across from Sharon during our initial visit, I was first struck by her eyes. Penetrating and defiant, they seemed to reject my recommendations before I spoke. I then noticed that her mouth was fixed in a scowl, and it looked as though this was its normal position. Lastly, her sharp cheekbones were framed by straight, long, brown hair. Her face seemed to warn the world that she was formidable and anyone seeking to interact with her should be forewarned.

	As I began to interact with her, I was careful not to dwell on the past. I did not want to appear accusatory and knew that, despite saying otherwise, she understood that her life was in jeopardy because of a poor decision she had made years earlier. Immediately, I realized that my initial impression was correct—she had a particularly guarded and defensive demeanor. Later, I learned that she was frightened and angry about her diagnosis. She was also vain and having had a mastectomy the month prior, she was particularly focused on her appearance.

	Later in the encounter, I was able to delve deeper into why she had initially deferred therapy. Sharon had deeply held beliefs regarding her ability to “self-heal” and she was highly suspicious of the modern medical system.

	To her, the intensive treatments we use in oncology were the worst of all. She felt that chemotherapy was poison, hormones would cause additional cancer, and surgery and radiation were horribly disfiguring.

	Over the course of my interaction with Sharon, I found that she appreciated succinct, direct language. Knowing that her prognosis now depended on my ability to develop a meaningful rapport with her, I firmly, but sincerely, asked her if she wanted to live. At first she was surprised by my directness, but her scowl soon softened and she responded that, yes, she did want to live. I told her that I could not promise her a cure because of the extent of her disease, but that if she trusted me and the medical system, we would give her the best chance of cure. She replied that she was ready to listen.

	Because Sharon already had a mastectomy, she would now need intensive chemotherapy to kill any remaining cancer cells. Many of her questions focused on practical issues. She wanted to know if she would lose her hair. I replied that, yes, she would most likely lose her hair, but we would arrange for her to wear a wig until it grew back. Feeling disfigured, she wondered if she could go to the beach after having had a mastectomy. Yes, I replied. I reassured her that we would order a post-mastectomy swimsuit for her to wear. Lastly, she had a new job as a dental hygienist and wondered if we could schedule her treatments around her schedule. I responded that, yes, we could arrange for her to arrive and leave early in the day.

	After thinking about it overnight and asking several more questions, Sharon agreed to initiate dosedense doxorubicin and cyclophosphamide followed by weekly paclitaxel. Despite pretreatment anxiety and many work-related obligations, Sharon did well throughout her intensive chemotherapy regimen.

	Toward the end of her treatments, I broached the topic of radiation therapy. Sharon’s major concern was that she would not be able to have breast reconstruction surgery afterward. This common misconception was dispelled after a visit to both the radiation oncologist and the breast surgeon.

	When I returned to Sharon’s hospital after rotating at another hospital for 6 months, she had completed her radiation therapy. Her formerly long brown hair was in a short pixie-cut, further defining her angular cheekbones. Sharon told me she liked her hairstyle and would keep it short, at least for a while. After spending some time catching up, our discussion turned to the hormonal therapy that I knew she needed, but did not want. Anticipating resistance, I had printed out information from an online prognostic model. After reviewing the evidence in favor of hormonal therapy and taking it home to discuss with her family, Sharon ultimately agreed to take these important pills.

	Despite her initial misgivings, Sharon has successfully completed surgery, chemotherapy, and radiation therapy. Additionally, she is adherent with her ongoing hormonal therapy. Sharon may not be cured, but she now has a second chance at life.

Tailoring your approach to how you interact
with a patient can be beneficial.

A Second Chance

Those were the words spoken by my favorite patient when I asked if he had enjoyed his time in the US Navy. Technically, doctors are not supposed to have favorite patients, but, since we are human, we all do.

I met Charles about a year ago during my first year of training as a hematology and oncology fellow. I remember him standing up slowly in the waiting room, cane in hand. Getting started took some time, but once he gained momentum, he could practically run.

I could tell immediately that he was a kind man, but this gentle demeanor was enveloped by sadness. I would soon find out that his wife had passed away several months prior to our first meeting, and he was in a state of bereavement.

Fortunately, he was not alone; he and his wife had raised 3 wonderful children. His daughter, Mary, often accompanied him to appointments along with her husband.

Charles was referred to our hematology clinic at the Jamaica Plain Campus of the Boston VA for pancytopenia, and for a man in his 70s, this laboratory finding was concerning.

Charles described to us how he lacked an appetite, was feeling increasingly tired, and had been losing weight over the past few months. He attributed these symptoms to his bereavement, but certain, more ominous, details emerged. He had developed substantial back pain about 6 months prior and was diagnosed with compression fractures. Additionally, he noted worsening dyspnea on exertion. Taken together, his symptoms were suggestive of a primary bone marrow disorder. He underwent a bone marrow biopsy, and the results confirmed our suspicion of multiple myeloma.

Between 1975 and 2006, the 5-year survival rate for multiple myeloma increased from 23% to 45%, with the greatest gains occurring after the year 2000.1

This trend reflects the myriad new treatments now available, including medications from entirely new pharmaceutical classes. Despite these advances, myeloma is rarely curable, and most patients will ultimately succumb to their disease. With this in mind, we started Charles on a very effective, and generally well-tolerated, regimen of lenalidomide and dexamethasone. Because of his age and comorbid conditions, he was not a candidate for bone marrow transplantation, so our goal was to put him into remission and keep him there as long as possible.

Unfortunately, Charles did not have the favorable initial response we had hoped for, and after 3 cycles we added a proteasome inhibitor, bortezomib, to his regimen. His myeloma responded, but again, not adequately.

After 3 cycles, his back pain worsened and it was decided that he should be treated with radiation therapy to his involved thoracolumbar vertebrae. Once his radiation therapy was completed, we initiated a new regimen, consisting of a traditional chemotherapeutic agent, cyclophosphamide, as well as bortezomib and dexamethasone (VCD).

Over time, I developed a professional friendship with Charles, and he told me more about his family, military experiences, and life after the military. In the US Navy, he served on 2 different vessels starting in 1959. He described, proudly, how the first ship he served on was an ice-breaker that ultimately went on to be the first ship of its kind to overtake an enemy ship. He recalled only good memories of being at sea, except, of course, for when there were severe storms.

After the military, his love for the sea continued, and he enjoyed fishing and lobstering from his 30-foot fishing vessel.

Recently, Charles completed his third cycle of VCD, and he now has stable disease. If and when he stops responding to this regimen, we have many more options available. For now, he is able to enjoy spending time watching his grandchildren grow up and excel at sports.

Charles’s war is not as dramatic as those we see in the movies, or even those recalled in the waiting room by his fellow combat veterans. His is one of attrition, with an enemy that cannot be seen with the naked eye. Although he may ultimately lose this war, right now, he is surely winning.

	1. National Cancer Institute. Fast stats: an interactive tool for access to SEER cancer statistics. Surveillance, Epidemiology, and End Results Program website. http://seer.cancer. gov/faststats. Accessed February 6, 2015.

Although this anecdote is based on a true event, names have been changed to preserve anonymity.

Those were the words spoken by my favorite
patient when I asked if he had enjoyed
his time in the US Navy. 

A War Story

I often find myself in awe of physicians who travel around the world seeking out the 2 most desirable aspects of medicine—patients in desperate need of medical care and patients with genuinely novel pathology.

The downside of this pursuit is putting yourself in harm’s way, through exposure to endemic infections or dangerous sociopolitical situations. If there were a place where it was possible to safely deliver care to those truly in need and encounter fascinating clinical pathology, then that would be an ideal location to practice medicine. Fortunately, I have found this medical Shangri-La at Boston Medical Center (BMC). As the running joke goes, patients step off the plane at Logan Airport, ask for the nearest hospital, and arrive at BMC. While we may not be the closest hospital to Logan physically, we certainly are the nearest hospital to these patients philosophically. On principle: we don’t turn anyone away.

As a fellow, my first clinic patient was a young man from Honduras who appeared fatigued. Upon examining him, I noted that he had a large spleen. As it turned out, the patient was coinfected with human immunodeficiency virus and leishmaniasis; his lab work also showed pancytopenia.

There was a serious concern that the patient had visceral leishmaniasis. A bone marrow aspirate and biopsy were indicated to help confirm the diagnosis and determine the etiology of his pancytopenia. Before long, we had the pathology results, which revealed leishmania promastigotes. The patient was treated with antiretroviral therapy and liposomal amphotericin B. As of this writing, he is still receiving maintenance amphotericin B treatments on an outpatient basis.

Later in the month, I had the opportunity to make a rare diagnosis, even for a hematologist. A middle-aged Haitian man presented with pancytopenia. His initial lab work revealed that he had a non-autoimmune hemolytic anemia as well as severe iron deficiency. During a return visit, the patient was asked about any source of bleeding and he confirmed that he had been suffering from hematuria for several months. Fluorescein-labeled proaerolysin variant testing confirmed the suspected diagnosis: paroxysmal nocturnal hemoglobinuria (PNH). Because of the large clone of CD59 deficient cells (60%), the patient was initiated on eculizumab therapy. Since beginning therapy, he has shown a vast improvement in his symptoms and cytopenias.

Each of these patients immigrated to the United States in search of a better life. While here, both patients were diagnosed with incurable diseases. Although the first patient may have been diagnosed in his home country, it is unlikely that he would have been able to receive the maintenance amphotericin B that is keeping him alive. The second patient never would have been diagnosed with PNH, let alone received costly infusions of eculizumab on a biweekly basis.

These cases were interesting from a clinical standpoint, but were made even more important by our ability to intervene and improve the length and quality of life for both patients. This is something we would not have been capable of if we had encountered these men in their respective countries.

Later in the year, I rotated on the inpatient service. Here, I had the pleasure of meeting 2 male Haitian patients with adult t-cell leukemia/lymphoma (ATLL) who presented classically with profound hypercalcemia. As my attending at the time said, “ATLL usually comes in threes.” I cannot imagine another place in this country that sees ATLL “in threes”—except, perhaps, Kings County Hospital in Brooklyn.

One of these men was older and had an aggressive lymphomatous subtype. He had comorbid conditions and had failed first-line therapy with zidovudine/interferon. He completed 1 treatment cycle of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with little response, and passed away after several hospital admissions.

The other gentleman was younger, and his course was particularly complex and heartbreaking because he was a Jehovah’s Witness. Consistent with his religious wishes, he refused blood products. This limited our supportive care and therapeutic options. Initial therapy with zidovudine/interferon was aborted due to cytopenias. Ultimately, he was started on CHOP and was able to tolerate 5 cycles before succumbing to his disease.

Our impact on these patients was not as obvious. They each presented with severe disease that likely would have ended their life immediately if they presented in Haiti, due to severe, refractory hypercalcemia. The first patient lived for several months with his disease but never achieved a durable remission. The second patient did not achieve a durable remission either, but lived for almost a year with his disease. Although the desired outcome of a cure or durable remission was not achieved for either of these patients, it was satisfying to be able to care for them and provide them the best chance of survival. This is the particularly gratifying part of working at Boston Medical Center. We take care of very sick patients, who have limited resources, in a fully state-of-the- art academic facility. Even when we fail, we know we provided our international patients with the best that modern medicine has to offer.

For a truly international medical experience, you don’t need to buy a ticket to South America, Africa, or the Far East. You will not need an active passport or a series of exotic vaccinations. You can simply hop on a plane to Boston and ask for the nearest hospital for those in need. You will be taken to Boston Medical Center, and will not be turned away.

I often find myself in awe of physicians who travel around the world seeking out the 2 most desirable aspects of medicine-patients in desperate need of medical care and patients with genuinely novel pathology

Christopher Dittus, DO, MPH

Articles

How to Survive With Limited Finances (and a Family) as a Hematology-Oncology Fellow

A Second Chance

A War Story

An International Experience at Home