From the earliest days of medical school, I had a special interest in hematology. This interest became stronger during my residency and culminated in a fellowship in hematology and oncology. The 3 years of my fellowship training were a life-changing experience that will stay with me forever.

I still remember the first day of my fellowship, when I was assigned to the general oncology clinic. The second patient I saw that day had end-stage lung cancer, and we had to discuss end-of-life care with him. I vividly remember the way my attending handled the conversation, which has had a lasting impact on me. Over the next 3 years, I experienced several tough patient interactions, ranging from the explanations I provided at the time of new diagnoses, to discussions on appropriate treatment plans, to end-of-life care discussions. At the same time, I found that the learning curve during these 3 years was the toughest since medical school.

It is a very exciting time to be in the field of hematology and oncology. The treatment paradigm for melanoma that I learned at the start of the fellowship has completely changed over the course of 3 years. As a first-year fellow in training, I found it very difficult to grasp all the information and apply it to patient care. Right from the beginning, it was important for me to focus on my overall career plan, which included identifying areas of interest in which to pursue further research.

I believe that the biggest struggle for many during fellowship is identifying longterm goals. It is important to identify them as early as possible if one is interested in an academic career. This becomes very important toward the end of the first year of fellowship or early on during the second year, to help plan for the remainder of fellowship.

It is also an important time to identify a mentor and a research project in one’s area of interest. It takes time to put together a research proposal, and therefore I cannot emphasize enough the need to start this process early. There is not enough time to complete a substantial research project in the third year alone.

Of course, the structure of the fellowship program varies throughout the country. Some programs emphasize clinical work in the first 18 months and devote the last 18 months to research. Some assign clinical responsibilities to fellows during the first 2 years and allow for a flexible third year devoted either to research or to clinical pursuits. For this reason, it is important for every fellow to identify the structure of their program early in their fellowship. This can help you establish your career goals.

In terms of an academic career, there are 3 different tracks one can pursue: a clinician- educator track, a clinician-investigator track, and a research track. In a clinician-educator track, the emphasis is on education for academic success. If you desire to pursue this track, it is very important to identify the correct academic program based on medical education contributions. A clinician-investigator track, more traditional in oncology, focuses on clinical trials and investigations; regular clinical duties are also included. A research track can involve either translational or basic science research. Translational research is definitely an exciting area in medical oncology, and one that allows for collaboration among those involved in bench research and clinical care. Again, I cannot over-stress the importance of planning for a career path early in your fellowship.

In terms of clinical practice, several variables factor into selecting the right practice. These include geographic location, availability of clinical trials and tumor boards, and the relative advantages of hospitalbased practice versus private practice. The healthcare system is changing, and many private practices are merging with hospital systems. This should influence your decision as well. If you join a private practice, it is important to consider the financial stability of the practice and the possibility of a partnership in the future.

I really enjoy hematology and I had always thought that I would be happy pursuing a career in pure hematology. However, I had very little laboratory experience prior to starting my fellowship. Therefore, right from the start, I knew I wanted to focus on clinical research during my fellowship training. Although I struggled with making clinical decisions during my first year, sometime during the middle of my second year it all began to fall into place, and I started making my own independent decisions. During this time, I was also chosen to be a chief fellow and thus became involved in organizing many teaching conferences for fellows, residents, and medical students.

Following the completion of my fellowship training, I became specifically interested in following either a clinician-educator track or clinical practice. Although I enjoyed the teaching and interaction with house staff in a university hospital setting, as I began interviewing for a position during my third year, I realized that patient care was what I enjoyed the most.

The American Society of Clinical Oncology predicts a shortage of oncologists by the year 2020. No matter what one decides, I think it is an exciting time to be in the field of oncology.

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The 3 years of my fellowship training were a life-changing experience that will stay with me forever.


Planning Ahead for a Career

 “Dr Narayan, aren’t you dating anyone yet? Maybe you work too much!” smiled Mrs Butler as she relaxed in her chair. Those tired lines around her eyes were gone. There we were in Exam Room 22, Nina’s room. I lovingly touched her soft, stubbly, baby-duck-like hair. This family had just lived through the worst 9 months of their lives, and now here sat their daughter, flushed cheeks and a cheerful smile on her face. Her recent test results revealed a perfect complete blood count and what one pathologist had described as “a beautiful marrow.” She was an acute myeloid leukemia survivor. “It’s growing,” she said self-consciously as she pulled her wig back on. I knew she wanted her hair back in time for high school graduation. That somehow seemed way more important to me than going on a date. I squeezed her hand. Nina is braver than I am.

As most of my colleagues discuss where to host their kids’ birthday parties or what to cook for their in-laws, I am mentally (or sometimes literally) scrolling through the list of guys on my dating profile, trying to decide who is worth getting dressed up for. I am a member of the cohort of 30-something single Indian women who were not lucky enough to snag the right guy during med school, and perhaps am not genetically engineered to be good at dating and studying simultaneously.

I am subsequently generally the oldest of my single friends and the “singlest” of my same-age friends. Culturally I am a spinster, a has-been, a “well-at-least-she’ssmart” per my grandmother, who is genuinely perplexed by the notion that tall, handsome, Hindu, vegetarian, Brahman professional men aren’t a dime a dozen.

Socially I apparently do not know how “lucky” I am to be alone, according to the fellow with marital problems, or the one who had to stop her whole career and relocate in support of her spouse. And so, counting my blessings, I throw myself into my work and the gym. Most days I leave both places feeling thankful and happy, and admittedly a little wistful for the day I can go home to cook for my husband or play with my own kids.

My days of fellowship generally end with signing clinic notes, preparing lectures for residents, or sending one last e-mail to the Institutional Review Board, pleading for approval of my research project. Many of my evenings entail putting on expensive makeup and uncomfortable shoes to go on yet another date, with a quick prayer before I run out the door. I push the elevator down button and tell myself with determination, “Maybe this will be the right guy,” as I fight to not think about the day’s events. Omar ’s leukemia relapsed again, leaving him very few options…little Corey’s brain tumor is gone, and now he can hold a sippy cup... Mara died last night after a long fight with a bleeding disorder… but Heidi, who honestly nobody thought would beat her cancer, started college today! The emotional ups and downs of the day are exhausting—which frankly makes it that much more difficult to listen to a guy state all his likes and dislikes over the appetizer. I get the familiar rant as he lets it be known he will not ever move from his current job, home, or city, so marrying him means “dealing with it,” all while he sprays a mouthful of crumbs in my face between words. Did I really pause my Netflix for this?

These days it seems there is another degree of screening involved. This is no longer only about this person getting along with my family and sharing my values. Can this person handle my career? Will he listen to me cry when a toddler with a brain tumor dies, one who let me hold her special dolly only 2 weeks earlier? Will he help me remember I did the best I could?

I think back to residency to the guy who was perfect on paper, who I thought had serious potential. I remember calling him over a tiny infant who had been beaten so badly she had 2 black eyes, only to have him say to me, “Your stories are kind of depressing—I really don’t want to hear this.” While I could hardly blame him, that was a game changer.

Remembering the advice of one of my favorite mentors during residency about “work-life balance,” I had always convinced myself I had that part in the bag. I worked my 80+ hours a week, went to the gym religiously, leaving just enough time for family and friends, and occasionally even slept a full 8 hours. I was balanced! I was happy. I had, after all, survived a major hurricane at my Caribbean medical school, a computer shutting down during the medical boards, and having “black cloud” status all 3 years of residency at a busy children’s hospital. 

. But my pediatric hematology-oncology fellowship has been the true litmus test of those statements.

There was this one afternoon in clinic, trying to teach a helpless young woman how to mix apple juice with chemotherapy into her infant’s bottle. I had flashbacks of helping my mom wash my then-baby brother’s bottles—the careful way she scrubbed them, the pride she took in filling them before we went out to the exact plastic fill mark on the side, working tirelessly to protect us with the precision only a mother has.

My heart went out to this wide-eyed, horrified mother as the nurse taught her how to pin her baby’s arms down to make him drink the bitter potion. Fifteen months old and no fair shake in life—I stepped out and cried in the clinic bathroom. No mom ever imagines having to deliberately poison her own child in order to save his life, and no mother should have to.

Your emotions and perspective change multiple times a day in this field. The question I get asked the most is some derivative of “Wow, children with cancer—how do you DO that job?” It almost seems silly to simply say “I hate cancer.” I think the real answer is selfish. It is because they make me a better person. They make me thankful. They make me appreciate every moment I can go outside and not have to worry that cold weather will trigger pain, treasure every moment I can eat, or play, or run, cherish every moment I can talk to my family and every moment I am lucky enough to feel love. No matter how broken my heart is from the one who didn’t want to work it out, I have a boundless love inside that makes me not want to give up&mdash;one that I gain from these children.

I realize if they can bear multiple IV needle pokes and severe nausea, I can bear a few more terrible dates until the right one comes along. I realize how lucky I am to have a mother who tells me to dress nicely to work because “There could be a handsome single doctor there,” and a dad who proudly tells anyone who will listen that his daughter is a pediatrician. I realize that you can feel close to other people’s children and love them with all your heart, in spite of some who are older and wiser and advise you to keep your emotional distance. I realize that parents can feel it when you care about their child, even if all their kid needs is a little more iron and a little less milk.

I realize every day what a privilege it is to care for somebody’s loved one. When a 6-year-old offers you his last Skittle as a “thank you” for his spinal tap, how can you feel anything but gratitude? When you see a dad come to the annual party with only his child’s framed photo in hand, instead of his actual son, you understand that the depth of one’s pain is a reflection of their , and that is a beautiful lesson to learn.

Although these anecdotes are based on true events, names have been changed to preserve anonymity.

I am a member of the cohort of 30-something single Indian women who were not lucky enough to snag the right guy during med school, and perhaps am not genetically engineered to be good at dating and studying simultaneously.

Work-Life Balance of a Hem/Onc Fellow

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. 

March 2015 | Oncology Fellows

Planning Ahead for a Career

Work-Life Balance of a Hem/Onc Fellow

A War Story