In her 2020 American Society of Clinical Oncology presidential address, “Equity: Every patient. Every day. Everywhere,” Lori J. Pierce, MD, challenges medical oncology to imagine a future when equity is considered a humanistic standard of oncology practice.

Earning this future will require a fundamental shift from passively observing disparities to actively promoting equity through behavioral change, social justice, and action.

 One area to begin this transformation is ensuring the next generation of medical oncologists comprehensively value and promote equity in practice.

The Accreditation Council for Graduate Medical Education (ACGME) made cultural competency (CC) a requirement in medical education in 2003, with specifics and standardizations emerging from 2010 to 2020.

 An important step forward, ACGME CC primarily focuses on securing therapeutic relationships with patients from diverse backgrounds by avoiding personal aggrievances and offenses. Programs also provide didactics on social determinants of health and cancer disparities. However, many of these discussions fall short of addressing ways to overcome barriers and provide equitable care.

More importantly, how training programs prioritize educational objectives and experiences communicates which are vital and which are not. The resulting sense of medical values, the “hidden curriculum,” is particularly influential in establishing professional identity.

 If the hidden curriculum contradicts the formal curriculum, instruction can become counterproductive and even enhance trainee burnout.

From my own teaching and learning experiences at 5 training institutions and 8 hospital systems, many programs struggle with equity in their hidden curricula, which inevitably detracts from efforts in CC, social determinants of health, and other parts of the formal curricula. Hidden curricula cannot be fixed by simply adding or removing components, but most programs could significantly improve their commitment to equity in education by:

recruiting and promoting career growth for historically underrepresented trainees and faculty beyond assignment to leadership roles in diversity, equity, and inclusion; 

promoting trainee engagement with diverse mentors and educators;

promoting learning collaborations between academic, hybrid, and community programs;

developing interprofessional education with case managers and social workers.

providing educational opportunities that showcase talents among underrepresented trainees;

discussing how historically ineligible or excluded patients can receive best standards of care;

developing longitudinal equity competencies with corresponding curricula.

Black and Latin peoples account for 13.4% and 18.1% of the US population, respectively, yet each group makes up only 4% of oncology drug trial participants.

 Demographically proportional enrollment—equality—would be an enormous achievement. To meet the definition of equity, trial enrollment must be sufficient to power hypotheses relevant to these populations. Increased funding opportunities for equity-focused oncology research is promising and helpful, but if equity is to become an integral part of oncology research, trainees must learn how to build equity into any research project.

To ensure premier research institutions are not simply acquiring grant funding to conduct outside research on underserved communities, research plans must include a commitment to community oversight and building capacity in partnering underserved institutions. Certain questions have been helpful in shaping my own commitment to equity in community engagement research, quality improvement, educational research, and clinical trials research in both academic and community settings (

Perhaps the most sensitive issue to confront is inequity in daily practice. Whether intentional or not, we must acknowledge that our current medical oncology system creates and continues to perpetuate existing disparities in cancer care. Recognizing this truth is not about assigning blame, but about understanding that equity in medical oncology will not occur without a change in practice.

Trainees can start by comparing their clinic and institutional demographics to the community and reflect on how their daily practice patterns contribute to or alleviate health disparities. If certain demographics are rarely encountered, programs should provide trainees with rotations at other institutions so trainees can appreciate what happens to groups their institution does not routinely see. Programs should also promote a culture of active accountability and stewardship over issues of financial toxicity and the unsustainable growth in cancer care costs.

Trainee groups should meet with their institutional medical director and chief medical officer to learn about the reasoning behind organizational policies that result in current practice patterns.

Although not every trainee will become an expert in advocacy or health policy, our training should ensure that all trainees appreciate how organizational, local, state, and federal policies affect a patient’s ability to access safe, affordable, and effective oncology care. Trainees can identify an issue pertinent to their anticipated career focus and present this issue at their state or national “Day on the Hill.” Trainees can also meet with cancer survivors from communities of historically disenfranchised peoples to understand the vastly different care experiences these groups receive and learn how to become an ally and advocate for these patients.

The final step to realizing true equity in practice is to ensure equity is not compartmentalized to work but becomes an instrumental life value. For individuals in historic positions of power, this means giving agency to minority voices in your daily life, actively listening, letting others lead, and leading primarily through supportive roles where success is defined by advancing the cause instead of personal ambitions or accolades. It also means being committed to improving as a person in addition to learning rules on how to interact with people of different cultures, accepting feedback, becoming aware of explicit and implicit biases, blind spots, and recognizing that good intentions do not equate with good deeds.

Establishing equity as an inherent value in medical oncology will require a comprehensive commitment to change. Training is a natural period when values and behaviors are shaped and influence long-term practice. Continued conversations on advancing the cause of equity are essential if we are to meet the challenge of providing quality oncology care to every patient, every day, everywhere.

Pierce, LJ. 2021 presidential address: equity: every patient. every day. every-where. ASCO Connections. June 7, 2021. Accessed August 12, 2021. https://connection.asco.org/magazine/features/2021-presidential-address-equity-every-patient-every-day-everywhere

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McDavitt B, Bogart LM, Mutchler MG, et al. Dissemination as dialogue: building trust and sharing research findings through community engagement. 

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Articles

A Challenge to Medical Oncology Training Programs: Promote Equity in Training

As we move into the autumn and winter conference seasons, I reflect on the impact 2020 left on the field of oncology. The year will be remembered for losses; the vast numbers of lives lost during the COVID-19 pandemic must not go unacknowledged.

The changes we experienced during 2020 ranged from the mundane, such as difficulty obtaining common household pleasantries, to vast economic downturns and strained health care systems. The oncology community, too, was forced to adapt to a world where personal interactions were discouraged if not forbidden. 

I had the great fortune to be selected as an oral presenter for the 2020 ASCO Annual Meeting, an event that transitioned to a completely virtual format for the first time in its 55-year history. I had to quickly became familiar with obscure names such as Zoom, Slack, Webex, Microsoft Teams, and GoToMeeting—names now woven into the daily vernacular of the world.

As a novice presenter, I was daunted by the prospect of a virtual oral presentation. On the other hand, it was opportunity for learning and growth. A subsequent oral presentation at the 63rd ASH Annual Meeting & Exposition in December would surely test my newly acquired virtual presentation skill set and enable me to consolidate what I had learned. 

The first challenge I faced when presenting through a virtual platform was keeping the audience engaged. A speaker can hold the typical adult learner’s attention for only 15 to 20 minutes. The 10- to 12-minute presentation time limit imposed by conference organizers, but I couldn’t depend on the clock to save me. 

The task then became how best to capture the audience through the screen in front of them rather than within a filled lecture hall. It was necessary to maintain strict attention to detail on the slide deck—aesthetics and judicious use of space had never been more important.

Some resounding core presentation components remained true: Use large fonts, present the most important points in bulleted lists, use discussion rather than writing in all prose, and present data in large graphs and tables. In this new format, there was no opportunity to explain away typos or errors and no opportunity for live questions or discussion with peers following the presentation. I made sure my slides were accurate and engaging thanks to insightful and sharp review of the presentation by colleagues. Their critical feedback helped me address any flaws in my delivery. The final presentation was the result of numerous revisions distilled to a finished product that required close teamwork with my mentors and collaborators. 

Sharing the study findings in the allotted time was the second challenge. While the time limits were reasonable, the phrase “choose your words carefully” took on new meaning. No longer did the speaker control the podium. Rather, a prerecorded presentation was carefully uploaded into the prespecified virtual meeting time slot. As a presenter, I didn’t have the luxury of additional time—each second was valuable, and I couldn’t waste time on fumbles and filler words. There was no ability to steal additional time at the end of the presentation or address follow-up questions that would allow me to explain anything that was unclear during the presentation. 

The key to clearing this hurdle was practice, practice, practice. I rehearsed the presentation again and again to refine the content and make sure my data could be understood in the time allotted. 

The ability to prerecord the presentation created its own obstacles. Given the value of allotted time, I often had to rerecord the presentation when a sentence was not articulated to my self-inflicted standards or I accidentally dropped in an extraneous “um.”

Filming from home added to the complexity. I don’t have a recording studio at home that would ensure lighting and sound were suited for recording a presentation to be delivered at an international meeting with a vast audience (ASCO reported recordbreaking attendance for its 2020 conference, with more than 40,000 participants from 138 countries).

Additionally, I knew that the presentation was a representation of my eff orts and the department and institution, as well as the patients and families enrolled in the clinical studies. The pressure to aim for perfection felt overwhelming. After multiple retakes, I finally realized that perfection is only an aspiration and to err is human. That helped me remain focused and on task, and that resulted in a successful recording.

The COVID-19 pandemic reshaped work life and home life as we knew it. It is also apparent that a virus is no match for human ingenuity and resilience. Virtual presentations imparted new challenges in the ongoing pursuit of sharing medical knowledge to advance cancer care during a global pandemic.

Moving forward, it remains unknown if virtual presentations will become a permanent feature of medical education. However, the challenges of virtual presentations left me with valuable lessons irrespective of the platform:

First, paying close attention to detail allows the delivery of a rich and engaging visual presentation. 

Second, obtaining critical feedback on the presentations from colleagues improves the quality of content shared with the audience. 

Third, rehearsing the presentation beforehand allows for smooth transitions and eliminating filler words enables sharp delivery of meaningful context. 

Fourth, creating a professional appearance and surrounding environment are vital and easily overlooked important components of the presentation.

Always remember the goal of presenting: to captivate the audience while conveying a message. Finally, embrace excellence— not perfection.

As the autumn and winter conference season approaches, Curtis Lachowiez, MD, reflects on the impact 2020 left on the field of oncology.

Best Practices for Virtual Conference Presentations

The American Society of Clinical Oncology (ASCO) projects significant shortages of practicing oncologists compared with patients with new cancer diagnoses and existing cancer by 2025.

 For an oncologist entering the workforce, this is valuable news. The job search for physicians in the COVID-19 and post–COVID-19 era will undoubtedly be different from any years before 2020. Nonetheless, fellows in hematology-oncology graduating in this time and recruiting in the next year will still have to go through requisite steps to secure desired jobs and positions. Through my own experiences this past year, I hope to highlight some key elements of the process, including unexpected pitfalls and pleasant surprises.

Growing up, I spent every vacation and many weekends in Maine, and even went to college in Brunswick, Maine. But, I didn’t learn about a nonprofit health care system called Maine Health until the 2019 ASCO Annual Meeting when I was a first-year fellow. Maine Health operates the state’s only academic medical division and is very closely affiliated with Tufts University, my residency alma mater.

I thought this would be a no-brainer in terms of personal and career fi t. I had my first job interview there in January of my second year of fellowship—nearly 18 months before graduation. The interview went well and both parties left feeling that we were close to being on the same page.

Summer came about and I went on my second, seemingly perfunctory, interview and thought that I had a job lined up. Ultimately, the job offered to me by Maine Health turned out not to be the one I thought I’d have. Instead, they had an opening for a community oncology job with academic affiliation in Brunswick.

The role and location of the practice did not match my expectations. It’s difficult to convey in print the disappointment that I felt at that time, knowing that I’d have to embark upon more interviews and that my dream of settling down in Maine as an academic oncologist would not yet come to fruition.

I uploaded my curriculum vitae to online physician job sites and within days I was fielding interview requests from health systems, hospitals, and practices around the country. I learned so much, so quickly about the job market only after opening myself up to various opportunities across the entire country. However, had this all happened later in the job search cycle, it would have been a painful lesson to not invest too heavily into your 1 potential dream job.

Consider Location and Employment Settings

As much as I love Maine, I knew I didn’t want to practice only in Brunswick. Location has a significant influence on the type of opportunities available to you and may affect the range of compensation you can expect. For example, New York City, Boston, and San Francisco are known for low physician salaries overall and hematology-oncology is no exception.

However, these cities offer copious opportunities for academic faculty positions because of their tight clustering of medical schools and cancer centers in a small geographical region. Similarly, these are some of the best cities for those considering a pivot to an industry job.

After several years as an academic oncologist, preferably with clinical trial experience, you will likely see high demand for your skill set from pharmaceutical companies, regulatory agencies, and clinical practices. A skill set that includes patient care and research experience allows for a transition to almost any oncology job out there, and major cities allow you to change jobs or industries while staying in the same area.

That said, there are advantages to working outside major population centers as well. There is great demand for well-trained oncologists to practice outside big cities in the United States. One in 6 Americans lives in a rural community and patients there have similar cancer incidence to those in urban centers.

I realized during my interview process that many communities with lower population density have impressively sophisticated medical communities where I could employ my skills and training. Contrary to most professions out there, physicians, including oncologists, are often financially rewarded for practicing in more remote locations. Many rural or suburban practices off er larger sign-on bonuses, loan repayment, and higher starting salaries than those in urban locations.

Finally, consider the implications of noncompete clauses in offers of employment when choosing where to work and live. In my experience, almost everything in a contract, including a noncompete clause, is negotiable, though sometimes unavoidable. However, if your contract includes a geographical noncompete clause and you work with the biggest player in a more remote community, you may be forced to move if things don’t work out.

Of course, there are benefits and drawbacks to the different types of oncology jobs (

). You’ll have to weigh financial considerations, potential for teaching or research, level of autonomy, influence over health policy, and overall population impact. During training, we have largely been exposed only to academic models of medicine, practiced within the confines of a hospital or health system, which does not encompass the full range of professional opportunities.

Personally, I had eschewed ideas of joining a private practice and only somewhat considered moving to industry. However, during this job search process, I realized that I highly value my autonomy and independence, and typically do my best work when I am my own sole motivator.

I also wanted to maintain a strong presence in clinical trials. I found a compromise by joining a private practice with a strong clinical trials program, recognizing in advance that much of my research time will have to come out of my free time after a potentially busy clinic day.

Some of my co-fellows chose to pursue clinical educator or research physician academic tracks at various academic centers where they will have to climb the ivory tower and navigate health system politics while writing investigator-initiated studies and building their reputations.

Whether you join a practice as a partner track junior physician, join a pharmaceutical company as an associate medical director, or join an academic center as junior faculty, gratification is unlikely to be instant. It will require hard work, consistency, and perseverance. Tian Zhang, MD, an academic genitourinary specialist and clinical trialist at UT Southwestern Medical Center, says, “Delayed gratification is gratification enough.”

In the end, aside from the perks and annoyances of our jobs, we must be content with the work that we do day in and day out. I hope you will explore many opportunities to discover your ideal job, and I hope that you will find fulfill-ment with the job you ultimately choose.

Yang W, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Prac. 2014;10(1):39-45. doi:10.1200/JOP.2013.001319

2020 Snapshot: State of the oncology workforce in America. JCO Oncology Practice. 2021;17(1):30. doi:10.1200/OP.20.00577

Feature Article

The American Society of Clinical Oncology projects significant shortages of practicing oncologists compared with patients with new cancer diagnoses and existing cancer by 2025.

Find the Job That’s Right for You

Recognizing the need to develop physicians who are well versed in basic science and clinical research in biomedical research, the National Institutes of Health (NIH) established the Clinical and Translational Science Award (CTSA) program in 2006. The program established CTSA program hubs designed to act as “catalysts and test beds for policies and practices that can benefit clinical and translational research organizations” throughout the United States.

These hubs provide funding opportunities to further support “preclinical innovation, clinical innovation, and multidisciplinary collaboration.” They also promote education and training to “develop the next generation of translational research physician scientists.” Aimed at growing the translational workforce, most hubs offer different accelerated advanced degree opportunities to oncology trainees, such as master’s degrees in clinical and/or translational research (CTR), or graduate certificates and courses in CTR.

The CTSA program currently supports more than 60 leading medical research institutions and medical schools.

 Not surprisingly, the vast majority of these research-focused institutions also sponsor graduate medical education (GME) and offer fellowship opportunities in different oncological specialties.

The question, then arises whether oncology fellows should take advantage of these programs during their fellowship training, and what the return on investment will be. Will it help in terms of career advancement? Will it increase productivity in terms of research output? Will it help junior faculty secure new funding opportunities?

Measuring the tangible impact of a graduate program on career development for physicians is complicated and, in some cases, highly individualized. Completing a master’s program in public health seems to have a positive implication on initiating a career as a clinical investigator.

 Obtaining a graduate certificate in CTR can have a meaningful effect on retaining faculty in CTR careers, as well as increasing the number of first and last author peer-reviewed publications.

However, there is little to no data available for oncology fellows to make an informed decision regarding the value of participating in these CTSA programs. Given the personal time and dedication required to obtain these advanced degrees while balancing clinical obligations and research expectations, knowing the potential pros and cons before embarking on the journey is vital.

With this in mind, my colleagues and I surveyed more than 225 practicing medical oncologists, surgical oncologists, and radiation oncologists who had completed a PhD, a master’s degree in CTR, a graduate certificate in CTR, or non–degree granting CTR courses to determine the impact on their careers and research productivity.

We particularly looked at the impact and satisfaction on new research projects, ability to secure federal and private funding, publications per year (stratified by years since completing GME), new job opportunities, and their career choices: academic vs nonacademic jobs and tenure track positions.

Regarding practice setting and tenure track, there was a significant difference between those who had completed a graduate degree and those who had not, suggesting that those who completed a master’s in CTR or a MD/ PhD were more likely to stay in academia instead of moving to a community-based or hospital-affiliated practice, industry, or private practice. We found no difference between professorship ranks in those who remained in academia.

Those who completed a master’s degree in CTR had higher satisfaction establishing new research projects and better ability to secure funding, and fostered new multidisciplinary collaborations both within and outside their institution (

 Research output satisfaction was also higher, but overall average number of publications per year was similar, suggesting that productivity can be attributed to other factors.

The perceived usefulness of their degree for career advancement was generally high among the group who had advanced training, again suggesting that completing a master’s program, for those already practicing independently, helped them achieve the job opportunities they were seeking and attain the professorship ranks they aspired to to advance their careers (

 Time and financial investment seemed to be well spent for those who were able to complete a graduate degree, supporting the notion that they had an overall good return on investment.

The high satisfaction noted in those with advanced degrees does suggest that additional training had a positive impact for practicing oncologists. Based on the results of our survey, medical oncologists, radiation oncologists, and surgical oncologists viewed their formal research education as a positive step in their professional development. Furthermore, respondents felt their formal research training was of particular benefit to those seeking to continue working in academic medicine.

Although not necessary to be a successful clinical investigator, master’s programs and other educational opportunities, such as graduate certificates offered by CTSA hubs, can help shape future physician-scientists. They can also help establish new connections with others at their institutions and in the region, leading to new ideas and advancement of the translational spectrum, ideally bringing novel drugs and therapies to clinical use faster.

CTR During Fellowship or as Junior Faculty

The data suggest that CTR training provides a significant benefit to career advancement. However, it is still unclear whether fellows should take advantage of these opportunities for formal research training while in training or as junior faculty.

In our opinion, various factors tip the balance toward completing advanced CTR training during fellowship. First, fellowship is a unique environment and phase of medical training in which one may have access to greater institutional support, including tuition remission, and protected time to complete additional studies. Second, although fellows have a rigorous schedule, they do not have demands on their time that they may later face as junior faculty, such as networking, administrative tasks, and other duties. Finally, during fellowship, trainees must decide the setting of their future practice, and completing a master’s program during fellowship is likely to foster success in academia on a more accelerated trajectory.

The constraints on a fellow’s busy schedule aside, it seems advisable to complete the CTR during fellowship. Whether a full master’s program in clinical and/or translational research or a graduate certificate, this training at this stage of education lays the groundwork for future productivity and professional satisfaction.

Aron Simkins, MD, is a medical oncologist at Mount Sinai Comprehensive Cancer Center, in Miami Beach, FL.

Zerhouni EA. Translational and clinical science—time for a new vision. 

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Leshner AI, Terry SF, Schultz AM, Committee to Review the Clinical and Translational Science Awards Program at the National Center for Advancing Translational Sciences; Board on Health Sciences Policy; Institute of Medicine, et al., eds. The CTSA Program at NIH: Opportunities for Advancing Clinical and Translational Research. Washington (DC): National Academies Press (US); 2013.

Kapoor K, Wu BU, Banks PA. The value of formal clinical research training in initiating a career as a clinical investigator. 

Comeau DL, Alvarez JA, Bhatti P, et al. Building diverse careers in clinical and translational research: evaluation of a certificate program in translational research. 

. 2018;2(1):38-47. doi:10.1017/cts.2018.19

Simkins A, Lee M, Paez W, et al. Impact of advanced clinical and transla-tional research educational programs on oncology specialties and career development. 

. 2021;39(suppl 15):11026-11026. doi:10.1200/jco.2021.39.15_suppl.11026

Aimed at growing the translational workforce, most hubs offer different accelerated advanced degree opportunities to oncology trainees, such as master’s degrees in clinical and/or translational research, or graduate certificates.

Oncology Fellows Derive the Greatest Benefit From Advanced Research Training

Like many physicians, Michael L. Grossbard, MD, knew he wanted to be a doctor at a young age. Grossbard’s inspiration came from his father, a hematologist/oncologist in northern New Jersey. 

“I saw the joy that he got from his job and the relationships that he had with his patients,” he said. “In that way, he was a role model for me in choosing to be a physician.”

Similarly, his interest in working with fellows goes back a long way—at least 30 years to his time on the fellowship selection committees for Dana-Farber Cancer Institute and Massachusetts General Hospital.

Grossbard earned his MD at the Yale School of Medicine and went on to complete a fellowship at Dana-Farber. He became the associate director of the Hematology & Medical Oncology Fellowship Training Program at the NYU Grossman School of Medicine in July after stepping down as director. He still leads many aspects of the training program at Grossman and sits on the ASCO Oncology Training Program Committee.

He always planned to complete a fellowship before moving into academic medicine, even if he wasn’t always sure what direction that career would take. He began treating patients with cancer during his medical residency and became intrigued by the innovative novel therapies of the time.

“I thought that the intensity of experience with patients was great,” he said. “The diseases were interesting, and I thought it was a place where I would be very happy making a career. There was a great opportunity to advance the field academically.” 

In this interview with Oncology Fellows, Grossbard talks about what to look for when choosing a mentor and a fellowship program.

What do you feel you gained from your fellowship experience?

I had what I would describe as a wonderful fellowship experience. I had great autonomy to take care of patients and to be intimately involved in making decisions about patients, and several terrific clinical and academic mentors. Some of the people I worked with back then—Robert J. Mayer, MD; George P. Canellos, MD—were giants in the field of clinical oncology.

On the research side of my fellowship, I was able to work with some brilliant people who were at the forefront of developing monoclonal antibody therapies early on in that field. I really treasure that time and worked with some very special people.

How do you help fellows pick a specialty?

We developed a mentoring program about 2 years ago. We start mentorship early in our program; everybody is assigned as a mentor—just a general mentor within the program, not necessarily an academic mentor—to help guide people. Then, as the training program director, I met with all the fellows multiple times during their first year of fellowship to get a sense of what they’re interested in and to tell them areas where I think there are opportunities. 

Then I help to guide them to people I think are good mentors. Mentoring is a skill that not everybody has. There are many people who are very well known nationally or internationally, or who are well published, but that doesn’t necessarily make them a good mentor or career developer. I try to direct people toward [mentors] who I know are good at modeling careers.

What should fellows look for in a mentor?

First, you want someone who’s available. You don’t want someone who’s looking after too many protégés or who has too many things going on at one time. You don’t want someone who’s traveling to academic conferences half the year. You need someone who takes your career to heart. 

Second, I look at track record, which you can’t always do for junior mentors. But for people who have been around for longer: Have they mentored people? Where have their protégés gone? Who worked for them, either clinically or doing clinical research in the lab? It’s important to look at a mentor’s track record of success as a mentor.

What should trainees look for when choosing a fellowship program?

It’s very important that fellows choose a program that is a good fi t for them, rather than just by name of program or reputation of program. It is increasingly hard, at least in the past 2 years, for people to see a program. ASCO [the American Society of Clinical Oncology] and ASH [American Society of Hematology] both recommend that [all fellowship] interviews will be done by video and not in person, so candidates don’t get to visit the place where they might work. Zoom interviews work to some degree, but there’s a wall [during virtual interviews] that is not there when you’re looking somebody in the eye. 

I would encourage people to reach out to colleagues who came before them in a program, or to reach out to current fellows in a program, to really explore carefully and choose the program that is the best fit. If you’re choosing a program because it’s prestigious, but all the fellows are basic scientists, and you don’t want to be a basic scientist, then don’t do that program. It won’t be a good fit. By the same token, don’t take a purely clinical program if you have some inclination to being in the lab. 

What do you hope fellows take from your program?

First, I want them all to be solid clinicians. Whether they’re going for a career in lab medicine, industry, or as a clinician, I want them all to be very good doctors. We put a tremendous emphasis on the clinical part of the training. Secondly, whether they’re going into academics, practice, or industry, I want them to understand how to conduct and interpret clinical trials. I want them to understand how to read literature. I want them to understand how to take a critical eye to the field so that they can at least always be thinking and not just accepting of something that they hear.

Dr. Michael Grossbard is section chief of Hematology at NYU Langone Health’s Perlmutter Cancer Center.

Michael L. Grossbard, MD, discusses what to look for when choosing a mentor and a fellowship program. 

Find Joy in the Job

Welcome to fellowship! You have mastered the art of internal medicine, served as the senior resident for a medicine team, and perhaps even served as a chief medical resident. Now you are a fellowship “frosh,” and are suddenly being called in the middle of the night to help a patient with hemophilia suffering with a complex bleed. You think, “Am I in over my head? Do I deserve to be here? Am I qualified?”

The short answer to all of those questions is yes. However, the answer we often say to ourselves in new situations is no.

What is imposter syndrome? Harvard Business Review recently published an article noting that “imposter syndrome is loosely defined as doubting your abilities and feeling like a fraud.”1 Although uncertainty is normal in a new situation, imposter syndrome reflects an underlying cognitive distortion. This is distinct from the feeling of being a novice, or someone who recognizes a steep learning trajectory as a part of skill acquisition. I have overheard fellows use the term “imposter syndrome” when talking about their worthiness for a job, worthiness to sit on professional society committees, worthiness to apply for competitive workshops, or even worthiness to provide a clinical opinion.

How do we address this feeling of “less than” and “unworthiness?” How do we embrace the concept that even our best selves are a work in progress and that we are worthy of opportunity and subsequent growth? How do we recognize that uncertainty can be a good thing as it provides a source of motivation to learn new skills and content? How do we recognize that humility is wonderful but should not interfere with our confidence? 

Sometimes things are easier said than done. Think about the following reframing steps when you feel imposter syndrome creeping in. You can use these steps when confronted with an event, or you can reflect on an entire day in order to help reframe any “stinking thinking” that undermined your confidence. 

We will use the framework of the aforementioned case. 

You’re a first-year fellow. You’re called at night for a consult by neurosurgery on a hemophiliac who needs urgent surgery because of a subdural hematoma. You know that you’re supposed to give antihemophilic factor, but you freeze and don’t know where to start. You are very uncomfortable with the situation and have the following thoughts: 

I am stupid. I should know this already. I am behind. 

If I call the attending, they will know that I am inferior to other fellows and may think I am stupid. 

I am not smart enough for this fellowship. They will realize that they made a mistake when they accepted me.

Identify the factual issues that are creating your anxiety. Make an objective analysis of your situation. Do not insert your feelings and do not mistake feelings for facts. For example, if you are the first-year fellow noted above, your anxiety and feelings of inferiority may be derived from the following facts:

You do not have a mastery of knowledge in this area. 

You are fearful of asking the attending on call a question.

Taken together, you have become a victim of cognitive distortion. By assessing the situation objectively, you can identify how to extricate the feelings from the facts. Your anxiety is rooted in your assigned negative perception of your abilities, but the reality remains that you are a new learner, and you are in the fellowship to learn. If you knew everything already, you wouldn’t be a fellow. 

Although you may not have the opportunity to self-reflect in the acute situation, these principals can be applied at any time.

An important component of self-reflection is the ability to recognize the areas in which objective data about your performance exists and to learn how to use that data to improve. For example, if you are a third-year fellow and don’t know where to start when treating a patient with hemophilia, then your concerns about your ability to practice independently soon may be valid. That still does not mean you are an imposter. Data can be your friend. 

Rather than reinforcing a feeling of incompetence, data provide a map to plan a path to proficiency. Examples of data include questions missed on the in-service exam, milestone assessments, and faculty feedback. This allows you to identify areas in which you need to concentrate. Remember that these sources of data were built to help an individual grow professionally. In fact, data assume that you are worthy and able to utilize the information in a meaningful way as you master your craft. You can improve. You are a learner rather than an imposter.

What would you say to a friend in the same situation? Why do we allow ourselves to trash-talk ourselves, but extend grace and empathy to a colleague in the same situation? The most important friend we need to comfort, encourage, reframe, and look objectively is ourselves.

We tend to think in binary terms—something is either all good or all bad. Even on a milestones rating scale for training, an individual trainee may assign “good” or “bad” to their milestone score. Keep in mind that even the milestones measures are meant to be a trajectory—you’re striving for progress, not perfection. Although it is healthy to ask, “How can I improve?” that is a very different conversation from, “I am bad.” You are all high achievers. You would not be in your current positions otherwise. That said, everyone will not score a perfect 5 out of 5. I urge you to embrace your imperfections—your “humanness”—as a key to avoiding imposter syndrome. Reframed uncertainty and imperfection are prizes in and of themselves. It is a blessing that provides all of us with the chance for personalized learning, academic growth, professional evolution, and the ability to flourish.

Tulshyan R, Burey JA. Stop telling women they have imposter syndrome. 

. February 11, 2021. Accessed July 22, 2021. hbsp.harvard.edu/product/H066HL-PDF-ENG

Jill Gilbert, MD, discusses overcoming imposter syndrome in fellowship. 

Vol. 13/No. 3 | Oncology Fellows

A Challenge to Medical Oncology Training Programs: Promote Equity in Training

Best Practices for Virtual Conference Presentations

Find the Job That’s Right for You

Oncology Fellows Derive the Greatest Benefit From Advanced Research Training

Find Joy in the Job

Overcoming Imposter Syndrome as a New Fellow