Only by the end of my first year of fellowship did I realize that beyond your fellowship experience there is a lot you can gain. Learning how to take care of our patients is definitely very important, but there is much more that we can gain from this period of our lives, specifically in terms of our learning. Whether you foresee a career in academia, private practice, or industry, there are opportunities available to you during this time period that will not be repeated.

It was after several conversations, looking over different curriculum vitaes, and spending endless hours surfing on the Internet that I learned most of the things I will share with you. Given my strong interest in breast cancer, my focus will be mainly on oncology, but similar opportunities are out there for those who are passionate about hematology or other solid malignancies as well.

During your fellowship experience, an amazing opportunity is to participate in writing a study protocol from beginning to end. This includes beginning with a discussion of the idea, writing a letter of intent (LOI) and submitting it for peer review, receiving funding, writing the whole protocol, getting institutional review board (IRB) approval, opening the study, enrolling patients, and hopefully, beginning to see results before you graduate!

The most difficult step may be finding an original concept and the appropriate mentoring in your institution for helpful, guiding expertise. Behind that is writing your LOI and perhaps submitting it to a workshop where your idea can be further developed.

For fellows and junior faculty, one of the most amazing experiences in clinical cancer research is attending the ASCO/AACR Vail Workshop that occurs every year during the summer season. The workshop includes 100 “students” with diverse backgrounds (medical oncology, radiation oncology, hematology, gynecology oncology, neuro-oncology, surgical oncology, and pediatrics) and a world-class faculty devoted to the students for a whole week.

The faculty includes outstanding clinical and transla- tional researchers, phase 1 experts, past and current American Society of Clinical Oncology (ASCO) presidents, biostatisticians, and patient advocates. The workshop is quite competitive, and if you are considering the use of an investigational drug provided by a pharmaceutical company, you need a commitment letter, so start working on it early. It will be worth it!

The American Society of Hematology (ASH) also has opportunities such as the Translational Research Training in Hematology Program to help you develop your own protocol.

The National Institutes of Health has several fellowship (F) and Career Development (K) awards that are worth exploring (http://grants.nih.gov/training/extramural.htm or http://www.cancer.gov/researchandfunding/cancertraining).

These are highly competitive but very prestigious awards to start your career with.

Another possible funding source for a fellow is the ASCO organization. In response to a need to recruit promising investigators into academic medicine, ASCO created the Young Investigator Award (YIA). In 1984, ASCO provided $16,000 for research in melanoma to Dr Judith S. Kaur, the first young investigator awarded with a YIA. Since then, ASCO has launched the careers of more than 700 fellows through its YIA program and has provided $30 million of research funding. The term of the YIA is 1 year, and the award currently provides $50,000 in research funding to award winners.

Other options for funding are available through the American Cancer Society (ACS), ASH, the Leukemia and Lymphoma Society, the Komen Foundation, and the Department of Defense (DOD), among other organizations.

When selecting an appropriate funding opportunity, you will want to consider your focus of research, prior research experience, level of institutional commitment, and citizenship status. Something to be aware of before you begin your application is that most of the grants are exclusive for US citizens, noncitizen nationals, or permanent residents. Except for K99/R00, most of the K awards from NIH are only available to US citizens or permanent residents.

For me, the best way to organize my projects is to have a deadline in my agenda. I suggest choosing a deadline to help keep you organized. It can be a deadline for a research workshop, abstract submission, or simply a date that you establish so that you have results before applying for jobs. This way, no matter how busy your fellowship is in terms of clinical responsibilities, you never lose sight of your goal.

Whether attending a scientific meeting for the learning experience or for presenting your own work, it is a great way to network with experts and meet fellows from other institutions. Getting to know fellows from other institutions has been one of the most valuable experiences during my training. It made me realize the strengths and weaknesses of my training, share experiences and available opportunities, and meet future colleagues with whom I will interact with for the rest of my professional life.

There are several reasons why you want to be involved with ASCO beyond grant opportunities. ASCO provides exceptional learning material available through ASCO University. Examples include the ASCO-SEP question bank (an essen- tial tool for boards preparation), tumor boards, diverse courses, flashcards oriented toward first-year fellows with basic oncology concepts, slides, and reviews of oncology literature.

You may also consider volunteering with ASCO and serving on a committee. No matter what your background, area of interest, or institution from which you come, we all can contribute. The best way to do so is by registering on the ASCO website (http://www.asco.org/about-asco/volunteerserve- committee).

You may also approach ASCO committee members and ASCO staff during meetings to express your interest. It may take time to get a chance to participate, but if you show interest, your opportunity will come. Similar opportunities are available through ASH and the American Association for Cancer Research (AACR).

There are other opportunities during the fellowship experience that can enrich your learning experience. These are diverse, depending on the areas of interest.

If you foresee a career in clinical research, something you may want to consider is applying for an external fellowship at the Cancer Therapy Evaluation Program (CTEP)/ NCI in the Investigational Drug Branch. This experience provides exposure to the review of incoming LOIs and protocols, and provides the opportunity to attend internal meetings between CTEP and pharmaceutical companies, or between CTEP and the FDA in regard to the development of new agents.

Another option is to apply for a rotation at the FDA. This opportunity will train you in federal regulations and the principles and practices of FDA medical product review, such as the design of clinical trials, monitoring of trials, identification of biomarkers, and clinical pharmacology.

If you are more focused on basic research, don’t miss some of the workshops AACR has available, such as the Annual AACR Aspen Workshop on molecular biology in clinical oncology.

	These Are the First Days of the Rest of Your Life

With all the available opportunities, it is important to confirm your initial decision that oncology is what you want to do for the rest of your life. Personally, I believe we are fortunate to have a very rewarding interaction with our patients and the privilege of sharing crucial moments in their lives. At the same time, we are part of a dynamic, evolving, ever changing and advancing field!

Filipa Lynce, MD, is a chief fellow in the hematology/oncology program at MedStar Georgetown University Hospital and MedStar Washington Hospital Center. 

Articles

Only by the end of my first year of fellowship did I realize that beyond your fellowship experience there is a lot you can gain.

How To Get the Most out of Your Fellowship

So it’s July 1 and you’ve finally arrived in the big leagues as a freshly minted first year hematologyoncology fellow. After having devoted the last decade to countless hours in medical school and internal medicine training, you have arrived on the final path of your ultimate career destination.

With the promotion to the coveted title of “fellow,” this exciting transition comes with the challenges of navigating through the foreign landscape of the vast field that is hematology-oncology. While it is true that some fellows may have the logistical advantage of resuming their fellowship training at their home residency institution, many of the growing pains that accompany the entry to fellowship are ubiquitous.

Almost within 24 hours of receiving this new title, patients (and even colleagues) will cease to acknowledge you as a board-certified/eligible internist. As they read “Hematology-Oncology” on your newly pressed white coat, they will expect you to address management and prognostic expectations at the level of a proficient oncologist.

I recall the excitement and apprehensions that overwhelmed me during my first days as a newly indoctrinated fellow. I have vivid recollections of the constant internal flurry of doubts regarding my ability to grasp my new role and my ability to master the daunting scope of hematologyoncology over the coming years.

Skeptical with concerns about my intellectual reserves and capacity for acquiring new knowledge after 3 arduous years of internal medicine residency, I was naturally distraught over the thought of an impending American Board of Internal Medicine (ABIM) examination, and triaging after-hours oncology pages, imparting prognostic information about life expectancy to highly anxious cancer patients, delineating esoteric side effects of chemotherapeutics I could barely pronounce or barely knew the indication for— oh, and not to mention&mdash;learning a whole new specialty. Nevertheless, as the year progressed, the dreaded ABIM boards came and went. Gradually, I was able to maneuver through National Comprehensive Cancer Network (NCCN), chemoregimen.com, and adjuvantonline.com, and I became accustomed to the many common chemotherapeutics we encounter in our daily practice.

Steadily, my apprehensions were allayed and I gradually was able to relay the expected treatment course for my patients and consider contingency treatment plans in anticipation of potential treatment failures for commonly encountered malignancies. I was even able to correctly pronounce many of the numerous tongue-twisting biologics that I used to cringe at the thought of during my early months of fellowship.

I became quite scarce during the many months that I was running the bone marrow transplant (BMT) unit or the inpatient oncology service. Between performing bone marrows, administering intrathecal chemotherapy, transcribing chemotherapy orders, teaching students and residents, and taking care of patients, I could hardly come to grips with where the day went.

Given such a hectic clinical workload, it was difficult to carve out dedicated time to read. Fortunately, reassurance from my senior fellows helped alleviate the guilt, as it is evidently a common theme during your first year. With that stated, it is important to find balance between inundating yourself in your new profession and taking time for yourself and family to enjoy your personal life. With time, I realized that this was the natural course of fellowship during the first year, and that over the coming years, I would have plenty of time to consolidate my knowledge and continually grow as an oncologist as so many have before me.

Most new fellows have inevitably interacted with consultants from their prior training/hospitalist experience. Unfortunately for some, they became the poor obedient intern who functioned as a human punching bag as an exasperated fellow went on a tirade over their allegedly requesting a “frivolous” consult.

I recall experiencing the apprehensions and frustrations of serving as a junior fellow for a busy consult service in my early days of fellowship. At times, it was vexing to carry the consult pager with its constant never-ending beeping, as it almost invoked post traumatic stress disorder flashbacks of my time as an overnight house officer not so many years before.

The infrequent but intermittent late afternoon lulls would be equally unnerving as I eagerly awaited the urgent 4:45 PM consult for a thrombocytopenia that the patient had experienced for the past 6 months. Many times, it seemed that I could never be accessible enough to my colleagues no matter how early I reported or how late I left.

While some consults may indeed be perceived as “frivolous,” I attempt to utilize every consult request as an opportunity to learn something new and teach a colleague with the hopes of ultimately improving the care of a patient. Invariably, I asked for thorough details regarding the clinical question meriting a consult—the patient’s history, presentation, and clinical course for the requesting physician to ensure that I had the information to provide a quality answer to their clinical question. Additionally, I went through my clinical rationale over the phone and ensured that I was clear on the question being posed.

Surprisingly, this exhaustive process occasionally results in an epiphany for the requesting team and sometimes provides the answer without necessitating a formal consult. The primary premise of going through such details, however, should be to induce thought, educate the requesting resident, and invoke a feeling of thoroughness.

Upon completing a consult, I learned that contacting the primary team to relay the final recommendations over the phone, or in person, not only served as effective communication but also resulted in fewer pages later on (just an added bonus.) I always remind myself that it wasn’t very long ago that I was a resident on the other side of the phone and the decision to consult may not always coincide with the opinion of the individual making the call, so you should attempt to be mindful prior to casting judgment on how “frivolous” the consult may be.

Whether your career goals lay in pursuing academics, industry, or private practice, it is especially important to find a mentor that will help coach you as you progress toward your ultimate goals. This is particularly true if you want to pursue an academic-based career. Scholarly performed activities during your training will distinguish you among your colleagues as you apply for eventual high-profile academic positions.

To maximize your opportunities, it may be more beneficial to enter a professional relationship with a seasoned faculty member who practices your tumor type of interest, as opposed to a younger faculty member who is right out of fellowship.

One of my biggest struggles during my first year of fellowship was acknowledging the importance of finding a mentor, as it would not be long before I had to apply for a “real” job; and without counsel the options may be far more extensive than you are ready for. Whether it be writing a review together, or becoming involved with a prospective clinical trial, working with the right mentor can serve as a substantial anxiolytic when contemplating your future professional goals.

All in all, as I approach the midway mark of my second year of fellowship, I reflect back with fond memories from my first year. While emotionally and physically taxing on a number of occasions, the experience was invaluable and one that instilled humility, patience, and gratitude for the opportunity that I am provided as a budding oncologist. Beyond becoming familiar with the technical aspects of cancer staging, chemotherapeutics, and prognostic indices, my new role has humbled me with the opportunity to engage in many meaningful relationships with my patients and their families during a vulnerable point in their lives.

Utkarsh Acharya, DO is a practicing Hematology—Oncology fellow at the University of Arizona Cancer Center in Tucson, Arizona.

After having devoted the last
decade to countless hours in medical school and
internal medicine training, you have arrived on the final
path of your ultimate career destination. 

In My Humble Opinion: Advice From a Second-Year Fellow

 I was filled with excitement and enthusiasm as I looked forward to my first day as an attending physician in medical oncology. The training was finally over and the dream was finally realized. I was my own boss— that too with a fatter pay check. All I had to do was put my training to good use. How hard could that be!

My first new patient had a large mass hanging out of their liver with test results that revealed normal liver function, positive hepatitis B, normal alpha-fetoprotein, and a CT scan result that read “kindly correlate clinically.” As a result of a 3-year practice as a fellow, my instinct led me to my senior attending’s room, where I stopped at the threshold and realized that now I was an attending as well. “Should I go in and ask for help or try to sort it on my own?”

, but this time it was different. I was not supposed to read to impress my attending and follow his directions; I actually had to make a clinical decision on my own. For the first time, there was no second opinion. My decision was the final one—the one that may be good but also could be bad. And not to mention the note I’d sign could not be changed. (God, I wished so much for paper notes at this point.)

To add to the shakes, the primary team wanted my opinion on the patient’s possible diagnosis and need for an abdomen MRI quickly because they were planning discharge.

While I was thinking, a voice came from behind me.

“Doctor, shall we talk about the patients on the list?” Little did I realize that I had been sitting at the computer for over a half hour trying to ensure that I was not missing anything.

Now, there were over 20 patients on the inpatient list and my team of residents, students, and fellow gathered around waiting for me to discuss everything with them. Needless to say, I didn’t want to sound stupid in front of the team. So I decided to run through the old patient list first and then talk about this new patient.

Most patients on the list already had a plan in place and I was relieved that things were running at a good pace, until another dilemma arose. This time, I was faced with a young, 40-some-year-old patient with metastatic colon cancer and multiple large liver metastases. This patient had an excellent performance status but very deranged liver function with a bilirubin of over 15 with no ductal obstruction. He desired chemotherapy and the oncology team could not discuss this in detail with him until now. So, as the new attending on the team, it fell upon me to go and speak with him.

My fellow asked, “So what shall we do in this case?” It took me a moment to gather my wits to say, “Hmm let’s see…what do you think?” And I did emphasize the “YOU.”

There was a pause which offered me the chance to breathe for a few seconds. Finally, the team revealed they were not sure how to proceed. Since we were going to see patients after lunch, I dismissed them a little early and asked my fellow to read up and enlighten us on the chemotherapeutic options for colon cancer with severely deranged liver function.

For the first time in my life I thanked God that I had a stubby neck so that my racing pulse could not be seen by anyone. I rushed back to my room and began looking up information on the computer to enlighten myself. Lunch was forgotten, but at the end of the hour I somewhat had a plan for both of these patients. I would order a biopsy for the first patient and speak to the other patient about a dosereduced chemotherapy option, if he wanted it.

Rounds were going well and the discussion was more fruitful than I expected. My team had a good expression of tranquility about our progress and I felt that I would survive the day successfully. And as we expect a storm to follow a big quiet, just minutes before we called it a day, a call came from an ear, nose, and throat (ENT) resident in the operating room about a new consult.

This was a 30-some-year-old young man with a tongue mass and neck nodes, whose biopsy results revealed malignant melanoma. I take pride in the fact that during my training I saw a few cases of malignant melanoma and treated them, but this mucosal melanoma was a first.

The ENT resident was asking for chemotherapy options for him. I told them I needed to review the case before giving my opinion. The team looked at me for what looked like a nice essay they expected me to provide about mucosal melanomas. Instead, what followed was somewhat shabby by my standards but made my team light up with a smile…I asked them to go home since it was close to 5 o’clock and I explained that I would take this consult on my own.

The team happily departed and I was left once again thinking back to earlier that day...“How hard could this be!” I finally decided to conduct research again. However, I also decided to get a second opinion this time. I walked to my senior attending’s room. The door was open and I knocked gently, feeling a little embarrassed. She gave me a big smile and said “Finally…I was wondering when you would show up.”

I was surprised. She explained that throughout over 40 years of practicing oncology, watching 100+ fellows graduate, she learned everyone has some jitters in the beginning. She continued to explain that at some point everyone asks for an opinion to make sure they are doing things right. It comes with the great responsibility bestowed upon us to treat these patients who come to us with barely any hope. It is our job to support that hope and work toward turning that hope into reality. Being human, we don’t want to make mistakes with such important and deadly diagnoses.

I sat with her for over a half hour discussing the things I was planning to do with all of my new patients, and to see if I got the hang of it I even discussed the old patients on my list. It turned out that I did have the correct plan for all of the patients, I was just not 100% sure of myself.

This experience took place over 2 months ago and I have grown as an attending tremendously since then. What I learned from this experience is that it is OK to be jittery and unsure in a new role. It is OK to ask for a second opinion, and it is OK to admit that there are things one doesn’t know.

It happens to everyone, some more than others. It seems that it is perfectly normal to be “new and nervous!”

Shweta Gupta, MD, is an attending physician in the Department of Medicine’s Division of Hematology-Oncology at John H. Stroger Jr. Hospital of Cook County, Chicago, IL.

It is OK to be jittery and
unsure in a new role. It is OK to ask for a second opinion,
and it is OK to admit that there are things one doesnâ€™t know. 

October 2013 | Oncology Fellows

How To Get the Most out of Your Fellowship

In My Humble Opinion: Advice From a Second-Year Fellow

New and Nervous