Diversity Strengthens Fellowship Training and Cancer Care

As the need for well-trained oncologists grows in the US, recruiting international students to fellowship programs will play a significant role in folling this demand, according to Jerome D. Winegarden, MD. Additionally, program directors and mentors must be privy to the challenges with acclimatizing to life in the US that sometimes accompany these fellows to improve their programs and equip the fellows to offer patients the best possible care.

“There are a lot of data [showing] that we don’t have enough oncologists and hematologists in the world, and in the United States, in particular,” Winegarden explained.

“[Approximately] one-quarter to one-third of physicians in the United States are international medical graduates [and they’re slightly] underrepresented in hematology and oncology compared with other specialties. You can call yourself an international medical graduate or not, but what we’re trying to do is put more hematologists and oncologists [out] into the world.
At this level of training, I try not to differentiate too much other than the support that they need.”

In an interview with Oncology Fellows, Winegarden, program director of the Trinity Health Ann Arbor Hematology and Medical Oncology Fellowship, a physician at Trinity Health IHA Medical Group Hematology/Oncology Association, and president of the Michigan Society of Hematology and Oncology, discusses what international fellows have to offer in domestic hematology and oncology fellowship programs as well as what institutions can do to better attract and train these fellows.

Oncology Fellows: What can international fellows add to an oncology fellowship program that is unique compared with fellows from the US?

Winegarden: I come from a community fellowship program that is relatively new; it’s been around for 5 or 6 years. It’s a little different than an academic [program] in the sense that our exposure to international medical graduates is [increased] because it’s well documented that most international medical graduates wind up in community residencies. It’s easier for them to find spots for internal medicine in those residencies, so my comfort level and exposure [are potentially] a little better than others.

When I use the filters to screen applicants, I don’t necessarily
put one in a higher category vs another: an international medical graduate vs a noninternational medical graduate. I’ve seen [that] the power that many international graduates bring is a lot of grit and tenacity that may not always be present in a noninternational medical graduate.

For a new program [such as mine], I am looking for people who are willing to [handle] the problems of starting a program with all the things that you pick up and learn over time. [International fellows] add a lot in terms of know-how and being flexible. Most international medical graduates are highly qualified. They’ve already done a lot, had life experiences, and have a level of maturity that’s not always seen.

Do international fellows have any specific needs that program directors must consider during their recruitment and training?

My experience [in general] is that many don’t need a lot. They’ve already hurdled issues in terms of getting here. [However], there are a couple of things. Making sure they have a community of people [who] are similar is important. I work in a relatively metropolitan area with enough groups of different people that they [possibly have] friends and family nearby who are in a similar situation; I believe they need community.

They [also] need time to take longer breaks than what may always perfectly fit into 1-week vacation blocks. I found that with the several [international fellows whom] we’ve had, requests come to take more than just a week off. Maybe it’s 2 weeks off so they can fly back home, which is usually a fairly long distance. It’s nothing that you would really want to do within a week, but 10 to 14 days [makes more sense]. Making sure they get time to see their family [is important]. I’ve also noticed that after fellowship, depending on visa status, helping to make sure that they’re connected to the right people to find opportunities, whether they decide to go back home or fulfill their need that they would require based on visa, [is crucial].

Where do oncology and hematology programs fall short in international student recruitment?

There’s a perception that a United States graduate is potentially more desirable than an international medical graduate. Providing information that we get as program directors during the ASH [American Society of Hematology] Annual Meeting [and Exposition] and ASCO [American Society of Clinical Oncology] Annual Meeting, the training program director meetings that occur several times during the year and also at the annual meetings [is important] to hear stories and hear the importance of why you want to consider all graduates who are applying, not just one group vs the other. Trying to overcome the shortcomings is basically realizing that there are other types of people out there [whom] you can put in your program, and they might even fit better than others. You have to keep your mind open.

What are programs doing or planning to do to address these shortcomings?

Right now, hematology/oncology is a very popular specialty. There’s very little advertising I’m doing to entice people to apply. For our small program, we take 2 new fellows per year and we get over 350 applicants for those 2 spots. [However], I’m still designing outreach and making sure our website is up to date.

When I speak with people, I make sure they understand that diversity, equity, and inclusion [DEI] is a part of our curriculum. We [not only] have a diverse population of patients to learn from, but also have [diverse] fellows to help those patients [to foster] learning for everybody.

It’s important to understand, in terms of this intersection of DEI and the idea of international medical graduates, that you are fulfilling portions of your DEI mission by making sure that you are including people from all different backgrounds. I’m not sure that it’s a way to entice [new fellows], but it’s a way to make sure that people are applying and know that we have resources. We have a community and the ability to hopefully make this a rich experience for them if they really want it. [In my experience], many international medical graduates don’t want special treatment; they just want to have their education.

How can these fellows be supported after entering the program to ensure their success in it and their careers?

This [question] just goes [back] to mentorship. I spend a lot of time with my fellows, and thankfully, I’m in a smaller program where I meet with them every week to talk about everything from well-being to little problems that may be coming up. Again, making sure that they know that support is there [is what matters]. Making sure there’s mentorship available is important for all our fellows.

In our faculty, we have...international medical graduates who can provide that type of mentorship as needed. They’ve been through these experiences and the hurdles it takes to come here to [the US] to finish training. That goes for after training, too; they can explain what their experience has been looking for jobs where they were and how they may have been perceived [in] one place vs another.