Safety and Efficacy of Axatilimab in Patients With Chronic Graft-Versus-Host Disease (AGAVE-201)

Videos

Zachariah DeFilipp, MD, presents data from AGAVE-201, a phase 2, open-label, randomized, multicenter study evaluating axatilimab at 3 dose levels in patients with recurrent/refractory chronic graft-versus-host disease (GVHD).

	As hematology/oncology fellows, we work with colleagues from multiple specialties. However, the majority of our interactions are with the internal medicine service, so here we will help you to maximize the quality of your interactions with internal medicine residents. In the following paragraphs, you will find many ideas that if followed will not just help you to “do your time” during fellowship, but contribute to the internal medicine residency program. And who knows, you just might inspire a resident to pursue oncology as a career!

	Generally, fellows work with internal medicine residents on the consultation service and on the inpatient oncology service. Thus, I will focus on these settings. At the end, there are also some general considerations that can be applied throughout your fellowship.

	The consultation service is the bread and butter of the hematology/oncology fellowship. As a future consultant, you are expected to develop the skills necessary to become an effective and efficient team player. Remember, you have been consulted for clinical guidance in answering a question, no matter how simple it may seem to you. The following is a list of points to consider:

 Residents are not born hematologists/ oncologists—there is a reason why they are consulting you. Belittling a consult only creates tension between the consultant and primary team. Treat every consult as a learning and teaching opportunity.

 It is imperative to know what questions the consulting team are asking. This is best clarified by speaking to the primary team directly. Oncology patients frequently have multiple problems. You do not want to write a detailed note regarding management of lung cancer when help is requested to evaluate thrombocytopenia.

Once again, this is best established by speaking directly to the consulting team. As 7fellows, we receive many consults of varying urgencies. Triage is of utmost importance. A 5 pm consult for thrombotic thrombocytopenic purpura is very different from a 5 pm consult for a mild chronic anemia.

Gather all patient-related information yourself.

 For an effective consult, every piece of clinically relevant data must be known. If this requires calling different offices and physicians, it is far more efficient to do it yourself than to delegate it to the primary team. We are often searching for specific information from a hematology/ oncology perspective, which the primary resident may not yet be qualified to address. Not only is this a fellow’s responsibility, but it also expedites the consult, preventing the patient and primary team from waiting in limbo.

When you’re finished writing your note, it is best to call the resident on the consulting team and verbally communicate your recommendations. Most training programs require that consultants not place orders on patients and instead allow the primary team to write all orders. This prevents multiple orders on the same patient and also serves as an opportunity for resident teaching. Speaking with the residents also results in quicker implementation of your recommendations. If you are unsure about the specifics of a recommendation, check with your attending before writing them down.

 It is important to understand your role as a consulting fellow. It may seem natural to comment on issues like electrolyte disturbances, hypertension, and diabetes with recommendations on how to correct them. This is especially true for first-year fellows who are just coming out of residency and are used to managing every aspect of patient care. These comments are often not welcomed by the primary team or other consulting specialties. Thus, it is probably better to stick with making recommendations specific to your expertise, unless there is a glaring issue.

 Providing an article addressing the consulting topic improves patient care and resident education. Not only will this give credence to your recommendations, but it will serve as testament to your commitment to resident teaching. The extra effort to provide education today may even save you an extra consult on a busy day.

 Your role as a consultant does not end with the initial consult. It is your professional responsibility to provide appropriate follow-up until the primary team is satisfied that their question has been answered. Consultation can conclude when the primary team feels comfortable managing the issue for which you were consulted.

	Many programs have inpatient oncology, hematology, or bone marrow transplant services with resident and fellow coverage. The fellow serves as the junior attending and is encouraged to make decisions regarding patient care, as well as to take an active teaching role. It is important to make these services worthwhile for residents so that instead of considering the rotation a burden, they see it as an exceptional educational experience.

 Do not consider residents as simply “help.” They should be treated respectfully, and it is your responsibility to look after their well-being. The service runs far smoother if the residents feel they are part of the team and not just there to do grunt work.

Learn to run an efficient service from the get-go. As the liaison between the attending and the residents, you will be in the best position to coordinate a smooth service. This ensures that the resident’s time is not wasted waiting for rounds to finish, etc.

 Teach residents on a daily basis. Be it a 5-minute talk on common hematology/oncology topics or reviewing board questions, residents will appreciate your commitment to education. With education incorporated into resident interactions, the internal medicine program will see the value and continue to staff the inpatient oncology service with residents.

Try to help out the residents from time to time in areas where there is no educational value, such as appointment scheduling and gathering outside records. This goes a long way in establishing rapport with your residents.

	Outside of the 2 major settings described, there are many other opportunities to contribute to the internal medicine program.

Attend morning reports as a subject expert.

 Hematology/ oncology patients are invariably presented at morning report. Since it is hard to be well versed in our specialty at a resident’s level, it is of great benefit to the program to attend these sessions. This develops a healthy relationship between yourself and the program and establishes your commitment to resident education.

Another area where you can pitch in is at board review sessions. Many internal medicine programs will arrange these sessions for their third-year residents. You can provide guidance in how to approach hematology/ oncology questions and identify the key issues. This is an easy way to enhance the quality of the internal medicine program and cement resident-appropriate teaching points.

 In every program, there are residents aspiring to be fellows like yourself. They will invariably want to get involved in research projects. Attendings are often hard to get a hold of, so you can serve as a great resource. Include residents in your research or develop ideas with them that they can pursue on their own. This act of goodwill will help them advance their careers.

	Following the above advice will not only help you train as an effective teacher and team player, but will add immense value to the internal medicine residency program. As future hospitalists and internists, today’s residents will look to your teachings in their care of patients with hematological or oncological problems. In the end, remember this twist on the famous quote by John F. Kennedy: “Ask not what your residency program can do for you, ask what you can do for your residency program.”

Articles

There are many ideas that if followed will not just help you to "do your time" during fellowship, but contribute to the internal medicine residency program.

Zachariah DeFilipp, MD

Articles

Safety and Efficacy of Axatilimab in Patients With Chronic Graft-Versus-Host Disease (AGAVE-201)

How Fellows Can Add Value to Their Internal Medicine Residency Program