There are 2 types of medical practice: retail and wholesale. Retail medicine occurs at the individual patient level in clinics, operating rooms, and hospital wards where physicians and patients work together to prevent and cure disease. Wholesale medicine, in contrast, occurs at the population and healthcare system levels, where policy makers set the rules that govern the retail practice of medicine. Physician engagement in the political process is an important mechanism for altering the trajectory of healthcare policy. This article discusses the wholesale side of medicine, exploring the why and how of physician involvement in healthcare policy.

Before we explore the how and why of physician involvement in healthcare policy, we will first define what is meant by this concept. In general, we know that a policy is a rule, or set of rules, designed to achieve a particular end by incentivizing desirable behavior. A policy aims to steer individual and collective decision making toward a predetermined goal. Based on this definition, we can conceptualize healthcare policy in terms of its goals and the means for achieving those goals.

The goals of healthcare policy are manifold. Up until the past decade, healthcare policy goals were commonly framed in terms of access, cost, and quality. Policy makers and thought leaders sought to expand access to care, minimize costs, and maximize quality. The conventional wisdom, however, was that the price for minimizing cost would always be paid either by diminished access to care or lower-quality care.

The past decade has seen an evolution in the framing of these healthcare policy goals. Borrowing from longstanding principles in management science, “value” has become the focus of healthcare policy. Defined by a direct relationship with quality and an inverse relationship with cost (value ≈ quality/ cost), this new value era in healthcare has combined the aforementioned policy goals of minimizing cost and maximizing quality into a single policy target. Framed in this way, the goal of healthcare policy is to maximize the value of healthcare such that it is worth expanding access to healthcare.

But if the goal of healthcare policy is to maximize value, the next question is, “Value for whom?” The constituents of healthcare policy makers include patients, providers, payers, and purchasers, and these highly integrated and related groups can have highly disparate perceptions of value. For example, for patients—the majority of whom are responsible for only a fraction of the total cost of their healthcare consumption&mdash;the value proposition is largely centered on maximizing quality. In contrast, payers (eg, private insurance companies) and purchasers (eg, employers that purchase healthcare services or health insurance on behalf of their employees) are more cost-sensitive.

Some providers, particularly physicians, have professional obligations to healthcare quality and patient welfare that must be balanced against the financial realities of managing a practice; however, other providers, such as hospitals, are not bound by professional obligations, but must deliver care in a manner that preserves operating margins. And while it may be appealing, often appropriate, and always politically expedient to elevate patient notions of value above all others, the answer to the question, “Value for whom?” must be an inclusive one. With this understanding of value, its multiple dimensions, and its place in the goals of healthcare policy, we now have an outstanding opportunity to explore how the next generation of physicians can engage and influence the value conversation in healthcare policy.

The means by which policy achieves its ends are rules that can influence the behavior of both individuals and the systems of which they are a part. For a rule to effectively influence behavior, it must be enforceable, and to be enforceable, it must be backed by the force of the law. This can occur in the setting of legally enforceable contracts between private parties, judicial rulings, legislative statutes, or administrative regulations. Legislation and regulation can occur at both the federal and state levels.

The opportunity for physicians to influence healthcare policy—both in its goals and the rules to achieve those goals&mdash;is greatest at the federal and state levels, where legislatures enact healthcare legislation and administrative agencies (ie, regulators) execute the legislation through a process called rulemaking. This is, in large part, due to federal and state government programs that provide health insurance coverage under Medicare, Medicaid, and the State Children’s Health Insurance Program. In administering these programs, federal and state policy makers not only influence the policies that govern the delivery of care for more than 40% of the US population (more than 130 million beneficiaries are enrolled in these programs),

 but they also influence the behavior of private healthcare entities, such as insurance companies, hospital systems, and physician group practices.

To illustrate the lifecycle of the legislative and regulatory process that culminates in healthcare policy, consider the following example: In 2010, President Obama signed the Affordable Care Act (ACA), which had been passed by Congress. The ACA, a broad and sweeping piece of legislation, directed the executive branch to promulgate a variety of regulations. One of the directives from the legislation was to create an “innovation center” within Medicare that would be responsible for developing and testing new policies for paying physicians, hospitals, and other care providers.

Based on this legislative mandate, and with a $10-billion appropriation over 10 years, the Center for Medicare and Medicaid Innovation (CMMI) was established in 2011. To date, CMMI has implemented dozens of payment models. One of the most recently proposed payment models includes the Medicare Part B Drugs Payment Model, published in the Federal Register in March 2016, which directly impacts how medical oncologists and other physicians are paid for delivering medications, including chemotherapy, in their offices or hospital outpatient settings.

Physicians need to engage in healthcare policy because it has altered, and will continue to fundamentally alter, the practice of medicine. Seminal moments in the history of healthcare policy, including the creation of Medicare and Medicaid in 1965,

 the Medicare transition to a hospital inpatient prospective payment system in 1983,

 the development of the New York state clinical registry for cardiac surgery in 1989,

 and many others, continue to have a significant impact today. Without real-world input from the physician community, we risk letting policy development occur in a vacuum, almost certainly resulting in disruptive and detrimental downstream consequences in healthcare delivery.

To illustrate the impact of involvement in the healthcare policy process, consider the Comprehensive Care for Joint Replacement (CJR) model.

 This bundled payment model was proposed by CMMI, in July 2015 and finalized in November of the same year. The payment model is a mandatory 5-year program that bundles the hospital, physician, and post—acute care provider costs over a 90-day period for total hip and knee replacements. Hospitals in the model that perform a hip or knee replacement will be financially responsible for all related Medicare spending in the 90 days following discharge. If 90-day episode spending exceeds prospective target prices, then these hospitals may owe Medicare a repayment amount. However, if this spending is less than the prospectively set target prices, these hospitals may receive a portion of that savings.

The proposed CJR rule did not incorporate any clinical risk stratification in the bundled payment policies. As a result, hospitals performing hip and knee arthroplasty would receive the same prospective target for patients regardless of the clinical indication for the operation. The response of the orthopedic surgery community to this proposal during the comment period was robust. Hundreds of comments were received by CMMI, particularly regarding the lack of any clinical risk-stratification. In response to this physician engagement during the regulatory notice and comment period, the final CJR rule was published with a risk-stratified payment methodology based on the presence of hip fracture. CMMI listened to the response from the physician community, confirmed that the need for adjusting target prices based on the presence of absence of hip fracture was supported by claims data, and then changed the final policy in response.

Although it is impossible to know what the final policy would have been without an organized response from orthopedic surgeons, it is highly unlikely that CMMI would have modified the proposed rule without input from providers.

The CJR rulemaking experience proves that physician involvement in the healthcare policy process matters and that such engagement can result in better policy making.

Given this understanding of what healthcare policy means and why it matters, I close with a series of recommendations on how physicians can get involved in shaping future policies. The basic principle is to make your voice heard. So, the question is, how do we do this? There are 3 general approaches that all physicians can take to influence the trajectory of healthcare policy.

First, get involved in the advocacy efforts of your professional society. Professional societies are uniquely positioned to advocate effectively on behalf of physicians and their patients. These organizations are typically well funded and staffed with skilled personnel who are dedicated to monitoring and responding to healthcare policy developments.

This staff expertise translates into more effective and efficient advocacy strategies than can be achieved by individual physicians alone augmenting the policy impact of these efforts. In the CJR discussion above, for example, the organized response of orthopedic specialty societies allowed for a more rapid and appropriately messaged response than could be achieved by individual surgeons. The advocacy arms of these organizations are typically located in proximity to the federal legislative offices and executive agencies such that they can respond to urgent policy concerns in a timely and face-to-face fashion.

Having argued for increased involvement in professional society advocacy efforts, it is important to address a common physician concern: that the policy priorities of physicians and the organizations that represent them are not in alignment. Some physicians believe that the policy platforms promoted by their professional societies do not address the policy burdens borne by physicians in daily practice in the clinic and the operating room. Although it is reasonable to object to the policy priorities being advanced by professional societies, the appropriate response should be further engagement—not less. The policy platforms of specialty societies are built by individuals, not by organizations. As a result, these platforms can be restructured, a process that can only result from member engagement, not disengagement.

Cultivating relationships with elected officials and their staff is another important avenue for physician engagement in healthcare policy. Members of Congress have significant authority over healthcare policy through both the passage of legislation and oversight of the administrative agencies that execute legislation. These legislators, however, must be responsive to the full spectrum of public policy and are, therefore, rarely experts in the issues faced by physicians. This presents an opportunity for physicians, a highly respected voting block of constituents, to step in as subject matter experts who can support the healthcare policy efforts of their elected officials. Additionally, connecting with a legislator’s staff can facilitate ongoing communication with those members of the legislative team specifically tasked with healthcare policy issues.

Finally, physician engagement in the political process is an important mechanism for altering the trajectory of healthcare policy. Politics is a messy game, and physicians are justifiably reticent to engage in this space. The merit-based system of medicine that starts with competitive admission to medical school continues with matching in residency and fellowship and culminates in a successful practice at odds with the retail politicking and glad-handing that define the political process. Wanting to remain unsullied, many physicians simply refuse to participate. Although there is merit in this position, there is a practical reality that we, as physicians, must confront. The consequences of elections and the political milieus that follow are going to play an increasingly larger role in how we deliver care to our patients. If we choose to ignore this reality, the process will move forward without considering us or our interests. However, if we choose to participate in the political process, we can shape the political landscape and clear a viable path for effectuating our healthcare policy goals.

Physicians need to engage in healthcare policy, and there are several ways to become involved. Whether through engaging with professional societies, cultivating relationships with legislators, or becoming active in the political process, physicians can influence the rules that govern how we practice. We know that wholesale medicine matters, now we just have to own it.

Total number of Medicare beneficiaries: timeframe: 2015. The Henry J. Kaiser Family Foundation website. http://kff.org/medicare/state-indicator/ total-medicare-beneficiaries/. Accessed August 15, 2016.

Medicaid enrollment by age: timeframe: FY2011. The Henry J. Kaiser Family Foundation website. http://kff.org/medicaid/state-indicator/ medicaid-enrollment-by-age/. Accessed August 15, 2016.

Total number of children ever enrolled in CHIP annually: timeframe: FY2014. The Henry J. Kaiser Family Foundation website. http://kff.org/ other/state-indicator/annual-chip-enrollment/. Accessed August 15, 2016.

Berenson RA, Cafarella N. The Center for Medicare and Medicaid Innovation: activity on many fronts. Robert Wood Johnson Foundation website. www.rwjf.org/en/library/research/2012/02/the-center-formedicare- and-medicaid-innovation.html. Published February 12, 2016. Accessed August 15, 2016.

Medicare Part B drugs payment Model. CMS.gov website. https://innovation. cms.gov/initiatives/part-b-drugs. Accessed August 15, 2016.

Starr P. The health-care legacy of the great society. In: Glickman NJ. Reshaping the Federal Government: The Policy and Management Legacies of the Johnson Years. Princeton, NJ: Princeton Unviersity. Princeton University website. www.princeton.edu/~starr/articles/articles14/Starr_LBJ_HC_ Legacy_1-2014.pdf. Accessed August 15, 2016.

A framework for evaluation: predicted effects of Medicare’s prospective payment system. Princeton University website. www.princeton.edu/~ota/ disk2/1985/8516/851604.PDF. Accessed August 15, 2016.

Hannan EL, Cozzens K, King SB 3rd, Walford G, Shah NR. The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes. J Am Coll Cardiol. 2012;59(25):2309-2316. doi: 10.1016/j.jacc.2011.12.051.

Mechanic RE. Mandatory Medicare bundled payment--is it ready for prime time? N Engl J Med. 2015;373(14):1291-1293. doi: 10.1056/ NEJMp1509155.

Comprehensive Care for Joint Replacement model. CMS website. https://innovation.cms.gov/initiatives/CJR. Accessed August 15, 2016.

Medicare program: Comprehensive Care for Joint Replacement Payment model for acute care hospitals furnishing lower extremity joint replacement services: a rule by the Centers for Medicare & Medicaid Services on 11/24/2015. Federal Register website. www.federalregister. gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive- care-for-joint-replacement-payment-model-for-acute-carehospitals. Published November 24, 2015. Accessed August 15, 2016.

Articles

This article discusses the wholesale side of medicine, exploring the why and how of physician involvement in healthcare policy.

Wholesale Medicine: The Why and How of Physician Engagement in Healthcare Policy

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.

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

The pager beeped for what felt like the 100th time that day—I had just sat down to dinner, hopeful for a quiet break during my 24-hour outpatient call, and was already aggravated and tired. The hospital operator informed me there was a patient with breast cancer on the line calling about back pain. I groaned inwardly, hoping this would not be a long conversation. “What can I do for you this evening, ma’am?” I asked. The patient launched into a long description of multiple symptoms, none of which I could clearly identify as the reason for the call. Finally I broke in and asked, “Ma’am, is there something I can actually do for you tonight?” After a pause, she replied, “Yes, I am in pain, can’t you tell? I can’t believe this. You are one of the least sympathetic physicians I have ever talked to.”

This exchange left me stunned. Had I sounded unsympathetic? Normally, I prided myself on my ability to speak softly, demonstrate a caring attitude, and appear willing to serve my patients’ needs. Yet, it was late in the evening, I had spoken to multiple patients and families throughout the day, and I felt that my emotional bank account was overdrawn. This moment occurred during the middle of my first year of fellowship, and I felt overwhelmed by clinical responsibilities and a seemingly insurmountable learning curve. The question dawned on me: was I suffering from burnout?

As medical professionals, we know that this is a phenomenon to which few of us are immune. Physician burnout results in, and from, communication difficulties, mental overload, a shortage of time, and perceived loss of control. It has elsewhere been described as a “prolonged stress reaction,” characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.

Given the demands of patient care, documentation, personal life, and finances, it is no wonder that burnout happens to a lot of us. A recent Accreditation Council on Graduate Medical Education survey of residents’ assessment of wellness showed lower overall rates of well-being compared with the general population. A total of 24.5% of residents reported feeling “down, depressed, or hopeless” an average of 1 to 2 days during a 2-week period compared with 15.9% of the general population.

As oncology fellows, we encounter the daily struggle of life and death, leaving us susceptible to emotional exhaustion. We often use depersonalization as a coping mechanism when our patients are dying. The overwhelming amount of knowledge we must master over the course of 3 years of training could certainly lead to feelings of reduced personal accomplishment. This all makes burnout seem bound to happen. Thus, in our endless drive to quantify medicine, the inevitable question is: what do the data show? And does this impact our practice?

What contributes to burnout in oncology? There are a number of factors. On a daily basis, we are faced with life-and-death decisions, rely on toxic therapies with narrow therapeutic windows, and balance clinical judgement with patient preference (these may not always align). But despite our best advances, we may not be able to prolong life for many patients.

 Frequent exposure to death and suffering has the potential to lead to depression, cynicism, a sense of futility, and nihilism, 

which impacts both our perceptions of skill and our ability to emotionally connect with patients. Time in training, too, may be a factor; even at the medical school level, significant erosion of empathy occurs between the first and final years of education,

 a concerning trend given the time point at which both burnout and frequency of patient encounters intersect. Burnout and emotional exhaustion have been seen in every branch of oncology: various studies have demonstrated a prevalence of 25% to 35% among medical oncologists, 38% among radiation oncologists, and 28% to 36% among surgical oncologists.

So, how often is burnout happening at the trainee level? The results of a 2010 French survey of over 200 oncology residents showed that 44% of trainees reported emotional exhaustion and depersonalization, with 18% reporting abnormally high levels of each. The authors also found that burnout had a statistically significant association with the desire to either leave healthcare altogether or to change specialties,

 which may be related to the emotional toll that oncology practice can take. A 2014 US study published by Shanafelt et al in the 

 included 1345 fellows who previously participated in an American Society of Clinical Oncology In-Training Exam survey, referred to as the MedOnc ITE, which assessed fellows’ level of knowledge feedback on issues related to training. The study revealed a burnout frequency as high as 43.3% among first-year fellows. The frequency decreased as training advanced (31.7% in second-year fellows, 28.1% among third-years). A similar trend was seen with emotional exhaustion (42.7%, 29.4%, and 25.4%, respectively) and depersonalization (18.5%, 16.1%, and 13.6%, respectively). These improvements in burnout occurred in parallel with improvements in fatigue, satisfaction with work-life balance, and overall quality of life, which may reflect diminution of knowledge gaps and call responsibilities as oncology fellowship advances.

What do we know about how burnout affects our practice? Studies have shown that depression is associated with medical errors

and burnout contributes to impaired results on standardized testing. One study of internal medicine residents showed the effect size was roughly equivalent to an entire year of residency training (ie, median scores for burned out second-year residents were equivalent to intern scores).

Pointedly, longitudinal follow-up showed that residents who started with lower scores did not recover to the level of their colleagues during the course of training.

 Another study of burnout on internal medicine resident performance showed a correlation between emotional distress and medical errors. Each 1-point change on the 30- to 54-point burnout scales was associated with a 6% to 10% increase in the likelihood of reporting an error over a 3-month period,

 and burnout remained independently associated with errors after adjusting for fatigue and sleep deprivation.

 Given the prevalence of burnout and the impact on our practice, what can fellowship programs do to address this problem? Clearly, there is a need to address the stresses of caring for acutely ill or terminal patients as we learn the technical aspects of cancer care. Some studies have suggested that participating in peer support groups, receiving training on end-of-life (EOL) care, or learning about medical humanities during fellowship training may alleviate the emotional exhaustion that cancer care entails.

We are expected to perform as strong, untroubled professionals even in our darkest and most selfdoubting moments. This can make it difficult to identify colleagues in trouble or admit that we may need help ourselves. Data reported at the European Society of Medical Oncology Congress in 2014 showed a troubling trend among young oncologists: burnout survey data revealed that 73.4% of trainees and 82.6% of post-trainees never ask for support. Even more troubling was the news that 74% of respondents reported having no access to support services. Burnout was suggested as a possible contributing factor,

 which may have an influence on emotional exhaustion, as trainees fear either discovery or being perceived as less clinically competent. 

One method of creating support and destigmatizing burnout is by using group therapy. Balint training, an interventional method developed in the 1950s, is a form of group discussion aimed at helping physicians improve communication skills and overall doctor—patient relationships. During meetings, participants discuss cases, focus on clinical interactions, and practice interaction with a focus on empathy.

detailed a study of a 2-year program in which 84 oncology fellows participated in Balint-like discussion groups. Participants reported improvements in their perspectives of themselves as physicians, their ability to deal with emotional clinical situations, and their comfort when discussing the stress of home at work.

A second study in the Journal of Cancer Education outlined a bimonthly fellows’ luncheon where oncology and psychiatry attendings moderated discussions on topics such as breaking bad news, managing the depressed or angry patient, and complex family and cultural issues. Again, participating fellows reported high satisfaction with the sessions and improvements in their emotional well-being,

 suggesting that participating in group sessions can improve empathy and reduce symptoms of depersonalization and emotional exhaustion.

For the most part, the formal oncology curriculum focuses primarily on disease processes and therapeutics, not on clinical experiences, such as dealing with dying patients. Special effort is needed to openly discuss death, bereavement, maintaining empathy, and the inherent difficulty of EOL discussions. This effort is challenged, however, by our tendency to maintain a culture of resilience and toughness in “the war on cancer.” Often, acknowledging such issues comes only at the very end of life (if at all).

A study examining the relationship between fellow burnout and perceived preparedness for EOL care found that whereas 24.2% of fellow respondents reported high emotional exhaustion, lower emotional exhaustion scores were associated with explicit teaching about certain EOL topics. Fellows also reported less depersonalization and a higher sense of personal accomplishment if they had training on specific components of EOL care, such as explicit teaching on opioid rotation, instruction on when to refer a patient to hospice, and observations by an attending oncologist while leading a goals-of-care discussion. The authors concluded that although good EOL training may be associated with less burnout, additional focus on EOL aspects is needed.

The study of the field of medical humanities in its various forms may help oncology trainees and other physicians to rekindle empathy and cope with burnout. The use of narrative medicine to help tell, listen to, and reflect on personal stories has been shown to improve clinicians’ understanding of their patients not merely as objects of care, but as unique and fellow humans.

 This was demonstrated through an educational mindful communication program that included narratives of meaningful clinical experiences, significantly increased empathy, and reduced symptoms of burnout among physician participants.

Nevertheless, the majority of humanities-based medical education has focused on medical students and residents,

 A pilot program focused on physician and patient narratives, which included medical, radiation, pediatric, and neuro-oncology trainees at the University of Rochester, resulted in high levels of attendance, positive qualitative feedback, and an eagerness among participants to continue the program. The authors encouraged further development of such programs to allow rekindling of the empathy that oncology trainees already bring with them and thus re-humanize the relationships between physicians and their patients.

Of paramount importance, of course, is the concept of self-care. Individuals who pursue hobbies and engage in life outside of medicine are less likely to develop burnout and more likely to report a better quality of life. Taking just 1 day a week to do so can decrease the risk of emotional exhaustion and depersonalization. Other daily practices of self-care may include rewarding yourself with an early coffee break, taking a walk or a “time out” after a particularly challenging event, stopping at a window to take in nature, connecting with loved ones throughout the day, or practicing meditative breathing.

 Self-care is essential and has been shown to enable physicians to care for their patients in a sustainable way with greater compassion, sensitivity, effectiveness, and empathy.

Ultimately, there are a variety of reasons why, at some point in our training and subsequent careers, our spirits and hearts will be challenged by the very work we chose to do. Recognizing contributing factors and engaging in thoughtful ways of processing them (whether through group discussion, reflective writing, or personal habits) can combat the attendant risks of an emotionally challenging career. Doing so will help each of us continue to serve in one of the most noble of professions; most importantly, we will continue to do that work well, in the interests of the people who need us the most.

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This moment occurred during the middle of my first year of fellowship, and I felt overwhelmed by clinical responsibilities and a seemingly insurmountable learning curve. The question dawned on me: was I suffering from burnout?

Where There’s Smoke: Are Oncology Fellows in Danger of Burnout?

After attending a family event in California, I was landing in Chicago, the city I did my residency in, when my cell phone gained a signal and messages and e-mails started to pour in. It is amazing how technology captures our attention and plays a large role in day-to-day life. I had already been feeling anxious and restless during the flight, being disconnected from my phone. As I opened up my mailbox, there it was, an acceptance into one of the country’s best hematology/oncology programs at Baylor College of Medicine. Despite having just landed on the ground, I felt as if I had taken off into the air, much higher than the actual flight’s altitude. There was a sense of exhilaration as tears gathered in my eyes with deep satisfaction welling up my heart. My first thought was that “Dreams do come true.”

Patients Are Your Biggest Teachers and We Must Learn to Befriend Them

Deciding on a subspecialty during my medicine residency was not easy. In fact, my brother was the first one to prompt me to opt for hematology/oncology, as he himself was practicing surgical oncology and felt this would be a great option for me. A few close friends, however, disliked the idea because of my jubilant and perky, yet very emotional, personality. Everyone who even faintly knew me felt that I would become depressed when I would see my patients dying because of this ghastly disease, often regarded as, “The Emperor of All Maladies.” Nonetheless, I weighed my options and after putting much thought into it, I did finally make a decision to pursue hematology/oncology.

As I started my fellowship in January of 2013, every passing day and every single patient that I met with, strengthened my determination to master this subject. Fortunately, I had the privilege of connecting with indomitable faculty at Baylor and ever inspiring seniors and friends who helped me learn the fine details of the topic material and the art of managing patients with cancer.

At the end of the day, however, I must say that the most important teachers in this field are your patients. Beginning with their first scan, when a mass “concerning for malignancy” shows up, patients experience profound anxiety and curiosity. Physicians disclose the scan findings to patients, who then undergo pathologic diagnosis and are referred to medical oncology for consideration of systemic therapy. The first visit with a medical oncologist is the most crucial. The appointment can last anywhere from 45 minutes to an hour and a half. The patient will have a million relevant questions to ask about the exact diagnosis, staging, and their treatment options.

And, of course, the patient will ask the worst and most difficult question, “Doc, how much time do I have?” As a physician in training, I found responding to patients’ questions very difficult in the beginning. Beyond questions on diagnosis and stage, I struggled with how to answer questions related to prognosis or questions on the category-1 treatment options recommended for their cancer type. Slowly, however, I found that you do get a grip on how to handle these situations. It took me around 6 months to become comfortable establishing myself as a confidante and a friend to my patients.

When patients with cancer are waiting inside a clinic room, they are normally filled with a swirling storm of thoughts and emotions related to their diagnosis and prognosis. If they are an established patient, they are more concerned about treatment response and the possibility of disease progression. Therefore, it is of tremendous importance that we are not only good physicians, but also good friends with our patients.

Cancer Treatment Is Not a Destination, It is a Journey!

One of my attendings taught the fellows not to introduce ourselves as “doctors.” “They already know you are a doctor, you don’t have to reiterate that fact,” he would say. Now, when I enter the room and introduce myself, I tell them, “Hi, I’m Dr Kamboj.” Almost 100% of the time they ask me how to pronounce my last name. I normally respond with, “You can call me Jasmine, and I absolutely don’t mind that.” There is a sense of relief and comfort as I say this. Most of the patients start calling me “Dr Jasmine.” I feel I have won a battle when my patients come comfortably into my zone or territory and offer me their trust. As patients with cancer, they are literally placing their lives into your hands. Gaining their trust is vital, as we are starting this voyage together.

Once the diagnosis has been revealed to the patient, and prognosis and treatment options have been discussed, I feel the most significant next step is to “give them some space.” Not pressing on patients during the same clinic visit for their final decision, allowing them time to discuss their situation with their loved ones, and offering them all of their available options are critical points in care. When I say “available options,” I not only discuss the treatment for cancer, but also insurance coverage, drug assistance programs, social work help for sorting out a tough family situation, and transportation issues. For those of us who are in private practice, insurance approvals form a dominant part of such issues while for those who are in county settings, social assistance can be very taxing.

Most of the time when you throw the ball in a patient’s court they ask YOU to make the final decision on their behalf. They often say, “You are the doctor, and you know what is the best for me, so you decide what I should opt for.” At this point, we need to jump in as their shepherd and escort them along their path. When a patient is about to begin this frightful expedition, the key is to lay out the plan in 2 ways. First, explain the overall plan (eg, for locally advanced rectal cancer, chemotherapy and radiation to start, followed by surgery, followed by more chemotherapy). Second, we must tell the patient what to expect over the next few days to weeks. This may include discussing side effect profiles of chemotherapy or common side effects from radiation (although radiation oncologists would go over these details in their clinic, as well).

Patients should be aware of what to expect, as surprises are not pleasant for patients who are already going through a lot of turmoil. Often, when we are not clear enough in outlining the overall plan, a patient may be taken aback when they visit us after surgery only to have us reveal the plan for 4 more months of chemotherapy (again, following the example of locally advanced rectal cancer).

Remember That Both the Patient and the Doctor (YOU) Are Human Beings

We usually follow up with our patients every 3 weeks, or sometimes more frequently, to monitor their adverse effects and tolerance of chemotherapy. We should never shy away from adjusting the dose of chemotherapy based on their tolerance. Again, supportive care is critical. In this day and age, many chemotherapy treatments are not as harsh as they used to be. The key is to use the right supportive and prophylactic medications at the right time. Pain, nausea, diarrhea, malnutrition, anxiety, and depression are commonly experienced by patients with cancer, and there are excellent guidelines for the management of all of these conditions. Studies have shown that practicing good palliative care from the start of cancer treatment improves survival. Any oncologist can recommend chemotherapy, but what makes you distinct from the rest is how comfortably your patients sail through their treatments.

I feel that one very common mistake is maintaining a very serious environment in the clinic 24/7. Despite the fact that the patients who enter an oncology clinic are overwhelmed with apprehension, I feel it is essential that we don’t forget the basic etiquette of “being human.” Laughing with them, initiating a conversation with their accompanying family members, narrating your own experiences, letting them know the simplest things like, “It is not your fault that you have cancer,” asking them toward the end of encounter, “Is there anything else I can help you with?”, will go a long way in calming down the trepidation.

Of course, you have to make a judgement call regarding what to say and when. We cannot laugh during end-of-life discussions; rather, these conversations require a great deal of compassion and empathy.

As cancers doctors, we are in the habit of overexpecting and overestimating in certain circumstances. Most of us have type A personalities and always seek to achieve better in our personal or professional lives.

That principle also holds true for us when it comes to our patients. It is important, however, to us and to them to be able to identify where to put a full stop or a comma in the cancer treatment. Advising your patients to take a chemotherapy holiday to be able to make a trip to meet family and friends is most often well appreciated and does not adversely affect outcomes. To make a call to stop treatment after progression on multiple lines of chemotherapy or if a patient’s performance status rapidly deteriorates, is crucial. We must recognize that our job is to make things easier and better for them. Buying a few weeks extra at the cost of poor quality of life may not serve that purpose.

Like many others, I believe that medicine is an art. This is an area where having knowledge is only one part of the whole game. You must have attributes such as compassion, empathy, and humanness to be able to be a successful doctor. In oncology, these attributes are especially important as we often perform the task of giving bad news.

After our most powerful chemotherapeutic agents or targeted therapies fail, and surgery or radiation are not options due to widespread metastases, we need to inform patients about the futility of any further interventions. Not only must we acknowledge our limitations as a physician and the frailty of Western medicine, we must also suggest comfort care or hospice. By definition, this means that the patient has a life expectancy of 6 months or less. In actuality, in cancer medicine, it is often much less than that.

We must ensure that we explain to patients and their families the philosophy of supporting their emotional, social, and spiritual needs while addressing their symptoms. This helps care for them as a whole, as you are respecting their needs as a human being and their family members’ beliefs and wishes. Letting them know they are “not being abandoned” is of paramount importance to this extremely challenging discussion. Making yourself available, even when patients are in hospice, will do wonders. As I mentioned previously, cancer treatment is a journey, and we form a bond with our patients and their families. We should not abruptly break that bond.

I have led a bachelorette lifestyle throughout my fellowship. My 5-year-old son has been in India with my wonderful parents, who have always tried to make my life easier and more comfortable. For those of us who have families, I think it is essential to take time off and spend time with our families on a regular basis. Hematology/oncology is a rapidly changing subspecialty and demands persistence in updating ourselves with the latest developments. Needless to say, the emotional aspect of the field can sometimes impact us significantly. Once we are seeing a patient every few weeks, over a long period of time, we develop a relationship not just at a professional level, but also at a spiritual level.

The losses are inevitable. To be able to accept those losses with dignity and not get affected negatively by the fragility of human life is a must, in order to cater properly to our other patients. A doctor’s family and friends, therefore, are as important on this journey as the doctor, patient and patient’s family.

In the end, I would like to express my gratitude to God, who has offered me this opportunity to be able to take care of patients affected by cancer; my family (my mother, father, brother, and my little son who means the world to me), who have always stood by me and been a constant source of strength during some really testing times; my teachers, seniors, friends, and staff at Baylor, who have taught me some very important lessons in the subject and in life; and last, but not least, all of my patients, who have made me the person and physician that I am today.

It is amazing how technology captures our attention and plays a large role in day-to-day life.

Living Life and Discovering Its Deeper Meaning

To help inspire new fellows to pursue their dreams and to reinforce how training will make a huge impact in the future care of patients with cancer, Oncology Fellows recently had the opportunity to speak with Amer Zeidan, MBBS, MHS, an assistant professor of medicine (hematology) at Yale University, to hear his story about his path to landing his dream career.

Dr Zeidan just completed a hematology/oncology fellowship and a clinical research fellowship in myelodysplastic syndromes (MDS) at Johns Hopkins University, where he also earned a master of health science degree in clinical investigation. Prior to fellowship, Dr Zeidan completed an internal medicine residency program in Rochester, NY.

What triggered your interest in pursuing a career in hematology?

Before moving to the United States, Dr Zeidan graduated with honors (in 2001) from the Faculty of Medicine at the University of Jordan, the country’s oldest and most prestigious medical school. Dr Zeidan’s clinical interest is in the management of myeloid malignancies.

: As a medical student, my first patient in my first ever hospital rotation was a young kid with a refractory leukemia. I saw him daily for several weeks before he died from his advanced disease. This experience had a major influence on my life direction. Not only did it make me decide to pursue hematologic oncology as a career, but it also played a huge role in my decision to work in clinical research to help find a cure for patients with refractory leukemia.

Now that you have finished fellowship, what are you working on?

During your training, who has influenced your decision to pursue the career that you have chosen?

Aside from finally landing your dream job, what are some of your biggest accomplishments, thus far?

The best place to pursue these academic interests was the United States. I came to the United States in 2004 from my country, Jordan, to gain the necessary knowledge and expertise to become a clinical investigator in the field of refractory hematologic malignancies. I completed my internal medicine internship and residency at Rochester General Hospital, in Rochester, NY, before moving to Johns Hopkins University for my hematology/oncology fellowship.

: The focus of my clinical/ translational research is the development of novel therapies for MDS, acute myeloid leukemia (AML), and other refractory myeloid malignancies. I have been working on designing and conducting early-phase clinical trials with a special focus on immunotherapeutic and epigenetic approaches. After joining Yale University, I have become the principal investigator in several National Cancer Institute, Cooperative Group, pharma-sponsored, and investigator-initiated early-phase clinical trials. Additionally, I have an ongoing interest in effectiveness research and population-level outcomes research in myeloid malignancies, which I conduct within the Cancer Outcomes, Public Policy, and Effectiveness Research Group at the Yale Cancer Center.

: I was lucky enough to be guided and mentored at important junctures in my life by several world-renowned scientists and researchers. My first endeavors in clinical research started under the mentorship of Dr Meir Wetzler and Dr Peter Kouides, in Rochester, NY. I subsequently moved to Johns Hopkins University to pursue hematology/ oncology clinical research under the mentorship of Dr Steven Gore and Dr B. Douglas Smith, in the areas of MDS and refractory hematologic malignancies.

: I have been lucky to be a part of several important projects. I have authored more than 75 peer-reviewed publications, including more than 25 original research papers and several book chapters. I have also presented many abstracts at national and international hematology meetings and have delivered invited presentations at several prestigious institutions both in the United States and abroad.

We are currently in the final steps of analyzing the data of my first investigator-initiated trial using the immune-checkpoint inhibitor, ipilimumab, in refractory MDS/AML. This trial has a special spot in my heart, as it was the first protocol I encountered when I was at Johns Hopkins University before moving to Yale University and opening the trial there, as well. During this process, I have acquired a valuable combination of research skills, including protocol writing, data collection and analysis, and manuscript preparation and presentation. These efforts have resulted in being awarded the “Edward P. Evans Fellow” grant for clinical research by the MDS Clinical Research Consortium and the Aplastic Anemia and MDS International Foundation, and a “Young Investigator Award” by the American Society of Clinical Oncology. I was also able to obtain an institutional “Molecular Targets for Cancer Detection and Treatment Grant (T32) Research Fellowship” grant.

What are you looking forward to in the near future at Yale?

Reflecting back to fellowship, what factors or experiences were most beneficial in establishing your career?

What was one of the most challenging aspects of fellowship? How did you get through it?

What is your advice to those who are just beginning fellowship?

What deciding factors played in a role in your decision to pursue fellowship at Johns Hopkins University?

I feel that my supportive world-renowned mentors, my strong work ethic, determination, solid training, and successful track record in multiple research endeavors render me very well-prepared to effectively replicate, at Yale, the success I enjoyed at Hopkins.

: My goals, in the next few years, center on ensuring the successful completion of my transition into an independent clinical/ translational investigator in the field of hematologic malignancies, especially MDS. This process involves the conduction of several important investigator-initiated projects as a way of achieving this goal.

: Connecting with the right mentor was the most important factor in making my career choice. Dr Steven Gore has taken me under his wings and has fostered a great environment for me to explore my full potential in conducting both clinical trials and effectiveness and outcomes research in MDS, which subsequently became the focus of my academic career.

: Trying to balance my personal and professional lives has always been quite challenging, as it is for many of my peers. This was particularly difficult during fellowship; it was one of the busiest periods of my life. Having a supportive family and great group of friends and mentors has been crucial for me in figuring out how to achieve that balance.

: To think, from day one, about where they want to be at the end of their fellowship and to work hard during fellowship to achieve that. This is particularly important for those interested in research careers, as it requires thoughtful planning and identifying mentors who can help you find your way early in your fellowship. During a busy fellowship, it is quite easy to get distracted by day-to-day events and find yourself halfway through the fellowship without having thought about your career goals.

: The reputation of Johns Hopkins as a top-notch science institution and a leader in cancer research, especially in hematologic malignancies, was the most important factor in making my choice to pursue fellowship there. Meeting established and well-known investigators and scientists during the interviews, whom I could foresee being my potential mentors and collaborators, was crucial in making my decision.

Amer Zeidan, MBBS, MHS, an assistant professor of medicine (hematology) at Yale University, shares his story about his journey through training with Oncology Fellows, and talks about landing his dream career.

September 2016 | Oncology Fellows

Wholesale Medicine: The Why and How of Physician Engagement in Healthcare Policy

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

Where There’s Smoke: Are Oncology Fellows in Danger of Burnout?

Living Life and Discovering Its Deeper Meaning

Catching Up With Fellowship Grad Dr Amer Zeidan