Oncology Fellows: Making the Right Decision About Your Future

Mohammed Najeeb Al Hallak, MD, MS

I was in my last year of medical school in Syria when I lost my father to chronic lymphocytic leukemia. I had encouraged him to seek treatment after seeing him suffer from disease-related fatigue and early satiety because of his huge spleen. I never expected, with my limited knowledge back then, that rituximab could cause such severe tumor lysis syndrome with disseminated intravascular coagulation on the third day of its administration.

I had to take some time off from my school to close my father’s local business. Then, I worked as an English translator for a medical equipment company to earn what was barely enough to support my family. Eventually, I graduated from school and left for the United States to start the long path to becoming an oncologist.

After completing my internal medicine residency from the University of North Dakota School of Medicine & Health Sciences, I had to work for several years to secure permanent residency in the States. Since my dream was to become a physician-scientist and develop new treatments for patients with cancer,I completed a master's of science in clinical research design and statistical analysis from the University of Michigan. Finally, I started my ultimate journey as an oncology fellow at Wayne State University School of Medicine in Michigan.

One month into the fellowship, full of hope and passion, I quickly realized how deep and complicated this specialty is. It was very different from the medicine I practiced before; there are so many genomic alterations to learn—EGFR, KRAS, BRAF, HER2, microsatellite instability, and PD-1/PD-L1—before I could choose the most beneficial treatment for my patients. Plus, I had to master not only chemotherapy, but also immunotherapy and targeted therapies.

I needed to get up-to-speed quickly. Some of my friends suggested that I skim the National Cancer Care Network guidelines to gain basic knowledge on the management of common cancers. Others suggested I browse a small handbook; still others directed me to watch hematology-oncology board review course videos. I was not able to work on any research projects during the first year. I felt like a wrecking ball, swinging wildly from one rotation to another.

By the end of the first year, I started to develop a special interest in gastrointestinal (GI) cancers, particularly pancreatic cancer. I enjoyed managing those patients, trying to get them to surgery, then adjuvant chemotherapy, all while hoping for a chance of a cure. Even when the chemotherapy is only palliative, I loved the moment when my patient came back to the clinic after a few treatment sessions, free of pain, free of fatigue, and able to eat without bloating or nausea.

At the beginning of my second year, I chose my GI oncology mentor and established my GI clinic parallel to his. I was then introduced to our GI team’s basic scientist, who involved me in several exciting projects exploring new drugs for pancreatic cancer. I learned how to culture cancer cells, perform western blots, create patient-derived xenografts (PDXs), and develop pancreatic orthotopic mice models. I was fascinated by the tumor shrinkage some of these new drugs achieved in the PDXs.

I then started to get more involved in the clinical trials conducted under my clinical mentor’s guidance. I wrote my first phase II trial protocol to test a new drug combination in patients with pancreatic cancer, and I was able to get the protocol approved by the independent review board and the FDA. I also worked with my basic science mentor on a translational trial to test biomarkers in patients with pancreatic cancer. I was then honored to become a scientific member in the tumor microenvironment biology program at my cancer institute.

In the middle of all the excitement, while advancing my academic GI oncology career, I noticed that my prefellowship savings account was getting depleted. I began worrying that I wouldn’t be able to support my family if I stayed in the academic field after graduation. I told myself that it isn’t easy to find private jobs in GI oncology, and even if I found one, it wouldn’t satisfy my career goals.

I sought advice from a member of our faculty who has been in academia for 30 years. He told me, “You will not be poor as an academic faculty. Choose what makes you feel happy when you drive to work every day.”

By the end of the second year, I began to feel that pursuing an academic career in GI oncology with a focus on drug discovery was the right choice after all. Initially, I didn’t think I could run my own lab if I wanted to focus on conducting clinical trials; however, I found that collaborating with our GI basic scientist gave me what I was looking for: the opportunity to develop new treatments for pancreatic cancer from bench to bedside.

I was announced as the new chief fellow at the end of the second year. Soon after that, I started to work on the fellows’ rotations schedule and didactics curriculum. At the same time, I was preparing to start my interview season to find my future academic GI oncology position. Meanwhile, I got an offer to join a successful pharmaceutical company as a leader for their clinical trials pipeline.

The offer caught me completely off guard; joining the pharmaceutical industry didn’t even cross my mind when planning my future career. However, it was a great opportunity: lots of travel, a role designing the company’s clinical trials on cancer drug discovery, and of course, a higher income. For all its advantages though, a job in industry meant that I would miss the interaction I enjoyed every day with my patients. Ultimately, I decided to turn down the position.

I finally made my career decision and signed with my current institution as a junior GI oncology assistant professor. I’m currently leading several clinical trials as a subprincipal investigator under my mentor’s direction. In a few months, I will take over as the principal investigator. I am sure this will be the beginning of a successful academic career. I hope that one day I will be part of a team that finds new and promising therapies for pancreatic cancer.

Making a decision about your career is not easy, especially when trying to meet the tremendous challenges of fellowship. After I went through the experience of struggling to make a decision, I learned that my colleague was right: What matters in the end is what makes you feel happy driving to work every day.