The other day I had the chance to reflect on my first year of oncology fellowship. Looking back, there is a craziness to it all that is hard to explain unless you experience it. I want to share reflections from what seemed like a typical day, with some advice for first-year fellows and trainees.

Alarm at 5 am. Get dressed. Grab breakfast on the go. Chug a triple-shot espresso.

I am one of the first cars in the hospital parking lot and one of the last out. I wonder if and when things will get easier. I make up in hours what I surely lack in experience. Chemotherapeutics, genomics, and controversies on Twitter over P values. Too much to learn each day. I’m thankful podcasts exist to consolidate my learning.

I take the stairs up to the fellow room. This is the peak of my exercise routine. I sign into the medical record to review patient charts. My colleague asks why I look so tired. I don’t answer. Doesn’t he know why? The fatigue, physical and emotional, adds up.

Training to be an oncologist has made me, at times, an absent friend and a preoccupied husband. I tell myself it is worth it. We all have friends who suffered from cancer. There is meaning in this profession.

There are 19 patients today who are admitted with a variety of solid tumors. All of their ailments make my complaints seem trivial. Their loved ones sleep on couches, and the patients who can sleep barely get any rest because we constantly interrupt them with blood pressure checks.

I start my rounds, and each visit begins with the typical, “How are you doing today?” The question often seems rhetorical. Most of our patients don’t like to complain, and we never have enough time to really engage anyway. We triage through who can go home, who has an impending emergency, and who needs more investigation.

Two cups of coffee later, the nurses remind me it’s time for discharge rounds with social work. We discuss the diagnosis, prognosis, and discharge plans for each patient. We evade talks of hospice, even though it is often on our minds. Maybe we will discuss it during the next admission.

I lose track of time, and now I’m 20 minutes late to noon lecture. Food brings my co-fellows together. It’s the 1 hour of protected education. I am to learn about new advances for metastatic kidney cancer. It is during this hour when our fellowship group text flashes with puns and complaints. I send a few memes. I survey the room for smirks. Eventually, it’ll all be immunotherapy. I think that was the conclusion of the lecture. I promise myself that I'll re-review the PowerPoint slides in a few weeks once I’m on my elective.

It’s time to run the list with the residents. We have many consults to call and outpatient oncologists to touch base with. I begin my first email:

Dear Doctor: Your patient is unfortunately admitted with new-onset ascites. Her scans suggest disease progression. We have shared the bad news. We hope to tie in a few things before discharge to prep for your next visit with her and her family. Let us know if there is anything else you’d like us to coordinate while she is admitted. social work and palliative care have been by to see her. Thank you.

I wonder how many of these emails it took before bad news became routine for me. At some distant time, the suffering of both patient and family was palpable. I can’t remember when that feeling went away.

I start revisiting the patients with whom we did not have a chance to truly engage. The next hour will be the only time in my day where I am not discussing medicine. Following the advice of a mentor, I primarily engage with patients about their grandchildren, favorite movies, places to travel, and the glory of ice cream. I wish the residents had the time to join; instead, they are plagued with progress notes.

I wonder how my wife is doing. She’s at home and a few weeks pregnant with our first child. We haven’t had a chance yet to visit family and share the good news.

I send her a text. She has been waiting to hear from me and sends a warm note back. She asks if I’ll make it home in time for dinner. I check with the charge nurse who confirms no beds for admissions today. I text back, “I think so.”

I walk back to the call room and prepare for the handful of patients I will be seeing in clinic tomorrow. I then realize I forgot about Ms Jones, the new patient admitted last night. She is 85, lives alone, and lacks resources. All her children live on the West Coast. Her performance status is poor. She was too sick to discuss her condition in depth on rounds this morning, so I promised to come back later.

I pull a chair into her room to start our second visit and try to follow the script I’ve been taught. “Good afternoon, Ms Jones. I wanted to check in and see how you’re feeling. I know we didn’t get a chance to talk this morning. I’m all yours for the next few minutes before I have to circle back and check in with the team.”

Selfishly, I am trying to keep this brief, hoping to finally be home for dinner.

“Doctor,” she starts with a smile, “I may be an old lonely lady, but I know how this works. All of the faces this morning suggested this was going to be my last visit to the hospital. I don’t need to be here. Let someone else have this bed. I’ve lived a good life.”

Years ago, at my medical school graduation, I received a reward for humanism. My classmates voted me as the person they’d like to care for their ailing loved ones. Is this who they expected me to be?

Today, I’ve fielded numerous consults. I learned the second- and third-line therapies for what was once a lethal cancer with few options. I supervised and taught our amazing residents. I shared research plans with my mentor. I prepared for journal club. I gave advice to my favorite social worker about where to eat in Italy. Yet I blew off the few minutes that truly mattered.

Later that day, after signing out, I returned to see Ms Jones. She was still smiling, and it seemed as if she knew I’d return. She was ready to speak and I to listen.

After nearly a year, the experiences with patients are what truly matter in oncology training. We all want to learn how to treat, but it is more important to teach yourself to care. First-line treatment may change over time, but what remains constant is this: Patients are our greatest teachers. They want to live normal lives. And they put their trust us—even when we are not deserving.

This article was written by Ramy Sedhom, MD, a Hemotology/Oncology Fellow at Johns Hopkins University School of Medicine.

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Ramy Sedhom, MD, looks back on his first year of oncology fellowship and shares advice for first-year fellows and trainees.

Something Good Happened Today: An Oncology Fellow Reflects

My college roommate called on Thanksgiving to discuss his recent test results. He had been experiencing worsening headaches that weren’t going away. After the phone call, I broke into tears, knowing the road ahead. His mother, who would be heroic throughout the ordeal, texted me to confirm what she already knew: Her only son was going to die from a glioblastoma multiforme (GBM).

A few short months later, after 1 of his radiation sessions, he had a seizure. I received a call that he was admitted to the intensive care unit and intubated. The prognosis didn’t look good. His mother, tearful over the phone, kept repeating, “I’m so scared.”

As an oncology fellow, giving bad news can just beat you down. It’s been the most difficult transition from internal medicine. All throughout training, we do our best to help patients and their families. But there are more cases with happy, complete endings in internal medicine.

Caring for patients with cancer requires a change in perspective. The reward is the fight itself, the daily work. It’s the lives we’re able to save and the dignity we’re able to preserve in death. But the grief, I learned, is not limited to patients or their families. It is also an unaddressed part of the cancer continuum.

Over the 6 months following his diagnosis, I saw surgery, chemotherapy, and radiation treatments ravage my friend’s body. I spoon-fed him. I held back tears when I helped him to the bathroom at night. The last time I’d held a bowl for him to vomit, we were in our prime health, college students celebrating after a week of finals. Now, a few short years later, he was thin and had lost the ability to walk.

We tried to share some old stories, but he had trouble focusing. I couldn’t tell if it was fatigue or sadness that was pulling him down, but it deepened with each day. He told me that his favorite part of the day was being asleep—he was never sick in his dreams.

The disease was relentless. He no longer had the will to live. A few weeks later, I watched him drift into a coma in the intensive care unit where I rotated as a medical student. Days after that, I prayed silently at his funeral service.

I still keep in touch with his mother. She’s never regained her vigor, even though it’s been years since her son died. Every time our eyes connect, I can see her searching for him. I, too, feel a sense of guilt that is difficult to explain. Why was I so lucky to remain in good health? Should I ask how she is doing or not bring up her son? Do I tell her I miss him? Or will that make her relive a traumatic memory?

During a rotation 3 years later, I was discussing the care of a young patient with terminal GBM who was in the process of transitioning to hospice with some other residents. There were no viable treatment options left, and the care team muttered a series of negative commentaries on this young patient’s family and their reluctance to “give up” on life and “accept that he was dying.”

One of the more experienced oncologists had stopped by after clinic to see his admitted patients and shared a moment of compassion, surprising both the grumbling residents and the patient. “Sometimes,” he said, “there are things in life worse than dying.” I tried to comfort my patient’s mother while she broke down weeping. She was unable to hold her only son’s hand.

The senior oncologist was familiar with the grief and suffering that continues for all those who experience the loss of a loved one. He interrupted any arguments among the assembled doctors, helping us to imagine how the patient must have felt. And while I realize that situations will always arise that cause moral distress for providers, we must remember the uniqueness of the dying experience.

We cannot always choose who will be here with us to receive our love, but we can still choose to be loving, patient, and understanding. And this is how I remember those dying in front of me each day—that each story comes with a history of suffering, sacrifice, and pain.

The experience of losing my friend has affected how I approach patients’ family members as they’re watching a loved one die. It is easy for physicians to pontificate about what we think is best, but we often forget about the memories that extend beyond our interactions to their families and loved ones. There is no role for contention in a medical setting. Our care extends beyond our patients, to their wives, husbands, children, parents, and friends.

As a matter of good practice, I’ve begun writing letters to the families of patients I’ve cared for and lost. I share what I learned from caring for them, that it was certainly a privilege, and that it has prepared me to help a future patient suffering through a similar experience. I don’t know how the families take it, but for me it provides closure and an opportunity to recover a tangible piece of what was lost.

We all want to hold on to a few more moments with the people we love—we are never taught how to die. But always remember those you've have lost along the way. It humanizes the caregiver experience. I’ll forever miss my friend, but he has taught me so much about how to care for others.

Caring for patients with cancer requires a change in perspective. The reward is the fight itself, the daily work. It’s the lives we’re able to save and the dignity we’re able to preserve in death. But the grief is not limited to patients or their families. It is also an unaddressed part of the cancer continuum.

Ramy Sedhom, MD

Articles

Something Good Happened Today: An Oncology Fellow Reflects

What Oncologists Can Learn From Personal Loss